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 372,307 young adults (ages 20-24) in 2021. Of the 1.2 million women of childbearing age, 44.4% are White, non-Hispanic, 32.7% are Black, non-Hispanic, 12.2% are Hispanic, and 0.2% are American Indian/Alaska Native. Of the 1.5 million children and adolescents, 40.7% are White, non-Hispanic, 30.6% are Black, non-Hispanic, 16.6% are Hispanic, and 0.2% are American Indian/Alaska Native. Of the 372,301 young adults, 44.7% are White, non-Hispanic, 32.4% are Black, non-Hispanic, 12.7% are Hispanic, and 0.2% are American Indian/Alaska Native (U.S Census Bureau). According to the National Survey of Children’s Health in 2020-2021, an estimated 266,095 Maryland children and youth (ages 0-17) have special health care needs. The survey estimated that 22% of children and youth with special health care needs were White, non-Hispanic, 22% were Black, non-Hispanic, 10% were Hispanic, and 21% were Other race, non-Hispanic (NSCH 2020-2021 Survey).[1]
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, which is 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 (CY2022), there were 1,834,677 Marylanders who were enrolled in Medicaid.[2] During calendar year 2022, 714,292 children and adolescents (ages 0-22) were enrolled in the Medicaid Program at some point during the year. 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 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 2022 Kids Count Data Book (Annie E. Casey Foundation) overall ranked Maryland 19 in overall child well-being, which has increased in ranking from 24 in 2020.[3] 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 10.3% in 2021 according to the American Community Survey.[4] The infant mortality rate in Maryland saw declines from 7.4 in 2005 to 6.1 in 2021. However, there was an increase of seven percent from the 2020 rate of 5.7 deaths per 1,000 live births. There remains persistent disparities in infant mortality rates by race/ethnicity. For example, in 2021 the infant mortality rate for Non-Hispanic Whites was 3.7 compared to 9.8 for Non-Hispanic Blacks. In addition, 12.0% of the state’s children (ages zero to five) live in poverty[5] and 4.3% of children under the age of 19 (age 0-18) do not have health insurance.[6] 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 Dr. Laura Herra Scott, who was appointed in 2023. 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 of 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 $5.7 million[7] 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.
Overall, Title V and the MCHB aims to improve and continuously grow. During 2020-2022, the Bureau and Title V underwent the strategic planning process to identify six strategies to help the Bureau grow operationally. These key strategies are: 1) promoting Diversity, Equity, and Inclusion (DEI) practices and processes, 2) advance system and community focused population-based practice, 3) strengthen internal and external collaborations, 4) increase operational efficiencies, 5) Build further capacity of the MCH Workforce, and 6) Use Data to inform Action and Decisions. Title V staff incorporates these strategies in the daily operations whether it is to conduct annual DEI Trainings, develop standardized operating procedures, or integrate similar programs (e.g., perinatal care coordination) for further impact.
Maternal and Child Health Needs
Perinatal Health:
In 2021, the Maryland infant mortality rate was 6.1 deaths per 1,000 live births, an increase of seven percent from the 2020 rate of 5.7 deaths per 1,000 live births, and reflecting a 21 percent overall decrease from the average rate of 7.8 deaths per 1,000 live births from 2012-2016. The infant mortality rate for Non-Hispanic Blacks was 9.8, near three times the rate for Non-Hispanic Whites at 3.3.
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 7 FIMR teams as of FY 2022. 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 176 child deaths to local CFR teams during CY2022, of which 129 were reviewed by local CFR teams. The leading manner of child fatalities in 2022 was accidents, accounting for 28% of child deaths reviewed, followed by undetermined at 24% of child deaths reviewed. Approximately 34 cases reviewed were Sudden Unexpected Infant Deaths (SUID). Infant safe sleep promotion continues to be a Title V priority.
Child and Adolescent Health:
OFCHS and the School-Based Health Center Unit partner with Medicaid to monitor the percentage of children and adolescents who follow through with well visits. Maryland School-Based Health Centers represent an essential and innovative strategy for improving the health and education achievement of Maryland’s children and their families. During FY 2022, there were 95 SBHCs located in 17 of the 24 Maryland jurisdictions. 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:
The Office of Genetics and People with Special Health Care Needs (OGPSHCN) continues to focus on the core domains for CYHSCN: identification, screening, assessment, and referral; eligibility and enrollment in health coverage, access to care, medical home, community-based services and supports, transition to adulthood, health information technology, and quality assurance and improvement.[8]
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 Child Medical Services program, which is a payer of last resort, CYSHCN receives coverage for their healthcare. In addition, through partnership with Local Health Departments, community-based organizations and academic and clinical associations, OGPSCHN continues to focus on the national performance measures of medical home and healthcare transition.
COVID -19 Impact:
The COVID-19 pandemic continued to impact the State in 2022. During January 2022, the Governor issued a 30-day state of emergency as COVID-19 was overwhelming normal operations at hospitals. The Department of Health opened 10 COVID-19 testing sites, and in order to increase vaccination rates against COVID, the State provided cash prizes in a campaign called, “VaxCash 2.0 for booster shots.” During March 2022, Maryland was seeing a decline in COVID-19 cases at schools, and certain schools provided COVID-19 tests home ahead of spring break. During the spring, Maryland began to see a rise in COVID-19 cases. State and local health departments programs operated in a hybrid capacity during this year. Certain programs such as home visiting still operated in a remote capacity.
During 2022, Title V staff at both the state and local level continued to be 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.
Network Security Event Impact
During FY2022, the Department experienced a Network Security Event that resulted in the Department’s information and technology systems being taken offline out of an abundance of caution. The event started in December and was confirmed to be as a result of a ransomware attack. This event not only affected the MDH but many of the local health departments who are part of the MDH Information Technology system. The Network Security Event affected operations including accessing fiscal systems as well as essential data systems. For example, data from the Vital Statistics Administration are preliminary.
[1] Percents do not sum to 100 because each racial category was broken down into CYSHCN and non-CYSHCN (i.e. 22% of white, NH children were CYSHCN and 78% were non-CYSHCN). The survey also noted that counts were too low to break down other NH into American Indian or other racial/ethnic groups.
[2] Maryland Medicaid DataPort. https://www.hilltopinstitute.org/public-dataport/ Accessed 9 June 2023
[3] 2022 KIDS COUNT DATA Book. 2022 State Trends in Child Well-Being. https://www.aecf.org/resources/2022-kids-count-data-bookAccessed 9 June 2023
[4] American Community Survey. Maryland Data Profile. https://data.census.gov/profile/Maryland?g=040XX00US24#income-and-poverty. Accessed 24 July 2023
[5] Anne E. Casey. 2022 Kids County Data Profile. https://assets.aecf.org/m/databook/2022KCDB-profile-MD.pdf
[6] Maryland Coverage Trends. https://kidshealthcarereport.ccf.georgetown.edu/states/maryland/ Accessed 23 July 2023
[7] It includes $4.4 million to all 24 Local Health Departments through core funding, and $1.3 for Child Health Systems Improvement to Baltimore City.
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