This section puts into context the Title V Maternal and Child Health (MCH) program within the State's health care delivery environment and provides an understanding of the State Health Agency's current priorities/initiatives and the Title V role.

Overview & Authority

The Kansas Department of Health and Environment (KDHE) is responsible for administration of programs carried out with allotments under Title V. The Bureau of Family Health (BFH), one of six Bureaus in the Division of Public Health, administers the Title V MCH Services Block Grant program. The mission of the Bureau is to “provide leadership to enhance the health of Kansas women and children through partnerships with families and communities.”

Kansas statutes do not mandate comprehensive services for MCH populations except for Children with Special Health Care Needs (CSHCN). Pursuant to K.S.A. 65-5a01, a "child with special health care needs” means “a person under 21 years of age who has a disease, defect or condition which may hinder normal physical growth and development." Statutes and regulations detail program requirements related to direct health services, in which services and supports are available to individuals ages birth to 21 with eligible medical conditions, and all ages with conditions diagnosed through the state's newborn screening program. Kansas provides direct services for state-mandated eligibility criteria, care coordination for program defined eligibility criteria, and non-direct services through community partnerships to the broader CSHCN population, as defined by MCHB/HRSA.

KDHE convenes the Kansas Maternal and Child Health Council (KMCHC) and the Title V Family Advisory Council (FAC) to ensure ongoing stakeholder engagement, monitoring of Title V performance and outcomes, and provide opportunities to obtain input from subject matter experts to support innovation and early adoption of new strategies or initiatives on emerging needs, issues, or trends.

Kansas Demographics

Geography/Demography: Kansas, spanning 82,278 sq. miles, is divided into 105 counties with 627 cities.1 The U.S. Census Bureau estimates there are approximately 2,913,314 residents living in the state in 2019. Kansas has a unique geographic layout that ranges from urban to frontier counties. Within each of its regions there are few populous cities intermixed with multiple rural areas. For example, the South-Central region includes Wichita with a population of 389,938. Within that same region also lies Pratt with a population of 9,164. This is a good example of Kansas’ diversity where rural communities are influenced by mid-sized cities, and mid-sized cities are influenced by rural communities. This diversity provides challenges to service delivery but also presents an opportunity for sharing resources.2

Population Growth/Change: The Kansas total population increased by 8.4% between 2000-2019, including a 9.3% increase for males and a 7.5% increase for females. Population increased from 2,911,505 residents in 2018 to 2,913,314 in 2019, a 0.1% increase.2 In 2019, there were an estimated 35,325 infants living in Kansas or about 1.2% of the total population (2,913,314). Women of reproductive age 15-44 accounted for 19.3% (561,891) of the population.2 In 2019, there were 833,794 children and adolescents aged 1-21 years living in Kansas, which represents 28.6% of the population.3 Among families with children under 18 years, 20.1% are single-parent families versus married-couple families.4 According to the 2018-2019 National Survey of Children’s Health, 20.5% of Kansas children aged 0 to 17 years (est. 144,750) were identified as having special health care needs (SHCN). The prevalence of children with SHCN in boys and girls under 18 years is about the same, 20.2% (est. 68,326) and 20.8% (est. 76,423), respectively.5

Population Density & Peer Groups (Urban, Semi-Urban, Densely-Settled Rural, Rural, Frontier): The population density of Kansas was 35.6 inhabitants per square mile in 2019, an 8.2% increase from 32.9 in 2000. For comparison, the population density of the U.S. increased from 76.9 to 92.9 persons per square mile from 2000 to 2019, a 16.7% increase. In 2019, 36 of the state’s 105 counties had population densities of less than 6.0. The most sparsely populated county was Greeley, with a density of 1.6. The most densely populated county was Johnson, with 1,248.8 persons per square mile. During the 2015-2019 period, the population of the urban peer group increased by 2.1%, while the frontier, rural, densely-settled rural, and semi-urban peer groups decreased by 3.9, 3.1, 2.1, and 2.2%, respectively.2

Image Credit: University of Kansas, Institute for Policy & Social Research

Age: The median age of Kansans in 2019 was 37.1 years, a 5.4% increase from the median age of 35.2 in 2000. The median ages of males and females in 2019 were 35.8 and 38.3, respectively. Shifts in the population distribution by age from 2000 to 2019 included a decrease in the 35-44 age group of 14.0%. This decrease, and another of 7.3% in residents 45-54 years of age and increases of 69.1% in residents 55-64 years of age, and 54.5% in residents 65-74 years of age reflected the aging of the baby boomers. There were also decreases over the same period the number of residents in the 0-4 and 5-14 age-groups, reflecting several years of declines in the Kansas birth rate. Furthermore, there were 3.3%, 9.7%, and 12.8% increases in the 15-24, 25-34, and 75 and over age-groups, respectively.2

In 2018-2019, the prevalence of SHCN within the child population increased with age, from 10.4% of children 0-5 years, 21.7% 6-11 years, and 28.5% 12-17 years.5 The higher prevalence of SHCN among older children is likely attributable to conditions that are not diagnosed or do not develop until later in childhood.

Race/Ethnicity: According to the 2019 Census Bureau estimates, 75.4% of Kansans were White non-Hispanic and 5.7% were Black non-Hispanic. Hispanics made up 12.2% of the population.2 The race and ethnicity composition of women of childbearing age (aged 15 to 44) was estimated at 71.2% non-Hispanic white, 6.1% non-Hispanic black, 0.9% non-Hispanic Native American or Alaska Native, 4.4% non-Hispanic Asian and Pacific Islander, 3.0% non-Hispanic multiple race, and 14.3% Hispanic (any race).2 The Kansas population, like that of the nation, is becoming more racially and ethnically diverse. One-third (33.3%) of Kansas children and adolescents (1-21 years) belong to a racial or ethnic minority. Across the age groups, the percentage of young children (1-5 years) and young adults (20-21 years) that are part of a racial/ethnic minority is about one-third, at 33.5% and 31.7%, respectively. About 17.1% of Kansans aged 15-21 years are Hispanic, compared to 18.5% of young children.3 In 2018-2019, the prevalence of special health care needs varied only a small amount by child’s race and ethnicity. Of Kansas Hispanic children, 17.1% had special health care needs, compared with 21.6% of non-Hispanic white children.5

Diversity/Languages: According to the 2019 American Community Survey, among people at least five years old living in Kansas, 12.1% spoke a language other than English at home. Of the same, Spanish was spoken by 7.8%, and 3.1% reported that they did not speak English "very well." The Spanish speaking population has been steadily increasing, which mirrors similar trends at the national level. An estimated 92.8% of the people living in Kansas were U.S. natives. About 59.2% of these residents were living in the state in which they were born. Approximately 7.2% of residents were foreign-born. Of the foreign-born population, 41.1% are naturalized U.S. citizens, and an estimated 74.1% entered the country before the year 2010. Foreign-born residents come from different parts of the world with the majority from Latin America (53.9%), followed by Asia (30.1%), Africa (7.2%), Europe (6.8%), Northern America (1.3%) and Oceania (0.8%).4

Education: In 2019, Kansas compared favorably with the U.S. average in terms of educational attainment with 91.8% of people 25 years and over with a high school education or higher compared with 88.6% for the U.S. Thirty-four percent (34%) of Kansans had a bachelor's degree or higher compared with 26.3% for the U.S.4 About 10.0% of children (1-17) received services under special education compared to 8.9% for the U.S. For Kansas children with SHCN, 32.0% received special education or had an individualized education plan (IEP) compared to 31.0% for the U.S.5

Income/Poverty: For 2019, the federal poverty level was $25,926 for a family of four.7 Research suggests that, on average, families need an income of about twice the federal poverty threshold to meet their most basic needs.8 In 2019, based on the Small Area Income and Poverty Estimates (SAIPE), a lower percentage of Kansans lived in households with incomes below the federal poverty level (11.3% vs. 12.3% for the U.S.) and a lower percentage of children under age 18 lived in households with incomes below the federal poverty level (14.3% vs. 16.8% for the U.S.).9 In 2019, an estimated 97,920 Kansas children under 18 years of age were living in poverty. Five counties accounted for over half of all children (51,064 children; 52.1%) in poverty: Sedgwick (21,279), Wyandotte (13,872), Johnson (7,890), Shawnee (5,344), and Douglas (2,679). However, the rural southeastern portion of the state has many counties with high concentrations of children in poverty as well. In 2019, the percent of Kansas’ families living below the federal poverty level (7.5%) was lower than the U.S. (8.6%).10 Poverty was more common in families headed by single females with children in the household, regardless of race or ethnicity. In 2019, the percent of female headed households with related children under 18 years living below federal poverty level (35.1%) was slightly higher the U.S. percent (33.5%).10 According to the 2018-2019 National Survey of Children’s Health, Kansas children living at or below poverty had an increased prevalence of SHCN. Nearly one-half (47.4%) of children with SHCN lived in families with incomes less than 200% of the federal poverty level.3

The health of the economy plays a major role in the health status of the state’s MCH population as well as the delivery of MCH services. The economy in Kansas has been recovering since the economic downturn suffered during the most recent nationwide recession. The statewide gross domestic product (GDP), which measure the total economic output of a given area, has been rising steadily since 2010, with the exception of 2020 (decrease of 3.0%). In 2020, in Kansas, the GDP has increased in 8 out of the 11 major industries, with declines in the utilities, nondurable goods manufacturing, and information GDP. The median annual wage in Kansas currently stands at $38,670. The three top occupation titles in Kansas include “Office and Administrative Support” with an annual median wage of $35,880, followed by “Sales and Related Occupations” with an annual median wage of $29,790 and “Transportation and Material Moving Occupations” with an annual median wage of $34,140.  While the unemployment rate was the lowest in the state’s history at 3.4%, prior to the COVID-19 pandemic, many of those jobs are low paying which makes it difficult for many individuals and families to meet their basic needs. Those households most disproportionately affected are female-headed households, blacks, Hispanics, people living with a disability, and unskilled recent immigrants. Moving the low-income population into the workforce is a protective factor for today’s families.12

COVID-19 Pandemic Impact: For the period February 17-March 15, 2021, 22% of adults living in households with children delayed getting themselves needed medical care because of the coronavirus pandemic. An additional 19% of adults living in households with children never did seek the medical care they needed because of the coronavirus pandemic. For the same time period, 15% of households with children had little or no confidence in their ability to pay the next rent or mortgage payment on time, which differed by race/ethnicity. More than one in four Hispanic (26%) households experienced this compared to 13% of non-Hispanic white households. Also, for the same time period, 12% of households with children sometimes or often did not have enough food to eat in the previous week. This differed by race and ethnicity, with more than one in four Hispanic (28%) households reporting this problem compared to 16% of non-Hispanic Black households and 8% of non-Hispanic white households.15

Kansas (along with many other states in the nation) has seen a dramatic economic impact from the COVID-19 pandemic. The May 2020 unemployment rate in Kansas rose to 10%, a dramatic increase from 3.1% compared to one-year prior in May 2019. While this was lower than the national rate of 13.3% and a decrease from the April 2020 rates (11.9%), it is clear the pandemic has negatively affected employment and the economy. Seasonally adjusted job estimates indicate that as of May 2020 Kansas had gained back 17% of the jobs lost in March and April due to efforts to contain the spread of COVID 19. The March 2021 seasonally adjusted rates of 3.7% indicate that Kansas has gained back the majority of jobs lost due to the pandemic, a slight increase from 3.2% in March 2020 before the pandemic.

Kansas Tribes: According to the 2019 U.S. Census Bureau, the non-Hispanic Native American population in Kansas was 23,271, 0.8% of the total population. Kansas is home to four Indian reservations: Iowa, Kickapoo, Potawatomi, and Sac and Fox. American Indians of various tribal affiliations can also be found in the towns and cities across the state.16,17

It is not a requirement that someone be Native American to live on the Indian reservations; however, a non-Native American would be unable to build a home or live in tribal housing without the head of household being a tribal member. While many of the families who inhabit tribal lands are of mixed races, the head of household must be a tribal member to utilize tribal housing. In the event the head of household were to pass away or leave, the tribe could request that the non-Native parent and Native child leave tribal housing. The Potawatomi reservation is comprised similarly to that of a checkerboard in which areas of “tribal land” are surrounded by non-Native land, or vice versa.18

It is significant to note that American Indians/Alaskan Natives (AI/AN) frequently contend with issues that prevent them from receiving quality medical care. These issues include cultural barriers, geographic isolation, inadequate sewage disposal, and low income. Some of the leading diseases and causes of death among AI/AN are heart disease, cancer, unintentional injuries (accidents), diabetes, and stroke. American Indians/Alaska Natives also have a high prevalence and risk factors for mental health related issues, suicide, unintentional injuries, obesity, substance use, sudden infant death syndrome (SIDS), teenage pregnancy, diabetes, liver disease, and hepatitis.19

Revealing the disparities within Kansas Tribal areas by selected characteristics (2015-2109)20,21

Health Insurance Coverage & Medicaid/Children’s Health Insurance Program (CHIP)

Health Insurance Coverage: Data from the Small Area Health Insurance Estimates show that the percentage of Kansas children under 19 years old without health insurance increased from 5.1% in 2015 to 5.7% in 2019. After a low of 4.5% in 2016, there was a slight increase in the uninsured population under age 19 in 2017 (5.2%), a slight decrease in 2018 (5.0%), then an increase in 2019 (5.7%).11 The U.S. percentage also increased from 5.0% in 2015 to 5.6% in 2019. In 2019, nearly half (49.8%) of all uninsured Kansas children under age 19 lived in the four largest population centers: Sedgwick County (Wichita), Johnson and Wyandotte counties (Kansas City metropolitan area), Shawnee County (Topeka), and Douglas County (Lawrence). However, the southwestern part of the state, a largely Hispanic populated area where presumably many are not Medicaid or CHIP eligible, has many counties with high concentrations of uninsured children under age 19. The southeastern portion of the state (Kansas Ozarks), on the other hand, has a cluster of counties with high concentrations of children in poverty, as stated above, but the children are less likely to be uninsured than those in the southwestern part of the state. According to the 2018-2019 National Survey of Children’s Health, in Kansas, 97.2% of CSHCN were reported to have some type of insurance at the time of the survey: 53.7% had private coverage, 34.0% had public coverage, 9.4% had both, and 2.9% had no insurance.5 Based on the 2019 average monthly eligibility for Medicaid and CHIP, Blacks made up 13.8% and Hispanics made up 22.4% of eligible individuals but had rates of 22.4 per 100 people and 22.0 per 100 people, respectively. This puts the rate of Medicaid and CHIP enrollment for Blacks and Hispanics at 2.3 times higher than Whites (70.7% of enrollees) with a rate of 9.7 per 100 people.23,24

Kansas Medicaid: Also known as KanCare, Kansas Medicaid is administered through the KDHE Division of Health Care Finance. Medicaid provides health coverage for traditional Medicaid and CHIP. For most eligible groups, including children, pregnant women, low-income adults, people with disabilities and people with both Medicare and Medicaid dual eligibility, services are provided through a managed care model. Enrollees choose, or are assigned to, one of three managed care organizations (MCOs), who receive monthly payments from the state. MCOs are incentivized to ensure enrollees receive services that help reduce costs over time by improving their health and quality of life.22

Contracts with the MCOs require them to provide essential services through Medicaid, including prenatal care, well-child visits, preventive services, hospital care, medication, in home care, community-based services and nursing facility care. The MCOs also must ensure services are available statewide and at Medicaid-required levels. They may provide additional services not traditionally covered by Medicaid to help prevent hospital admissions or institutionalization. Additionally, Kansas has adopted seven Home and Community-Based Services (HCBS) waivers to provide flexibility around additional services not covered by Medicaid or CHIP.16 See the table that follows for a list of those waiver programs.

Image Credit: Kansas Health Institute, 2019 Medicaid Primer

Medicaid expansion is a current topic of discussion in Kansas. Kansas is only 1 of 12 states that has not expanded Medicaid coverage to all adults up to 138% of the federal poverty level. Several legislative initiatives have occurred in recent years, most recently in 2021; however, bills continue to be unsuccessful during regular legislative sessions. Other Medicaid policy initiatives listed below have been the focus for public health and Title V.

• Postpartum Medicaid Expansion: Extending Medicaid postpartum coverage to one full year vs. only 60 days has strong support. There is a plan to move forward with this administratively. A small Kansas team including the Title V Director, Medicaid Director, and consultants have been meeting over the last eight months to discuss the pathways and plan. Conversations with legislators and stakeholders will be taking place soon to increase understanding and gain support on the issue. The Title V team drafted an impact paper that will be utilized in conversations.
• Maternal Depression Screening: A new policy became effective January 1, 2021, which authorizes providers to screen for perinatal mood and anxiety disorders and bill under the child’s Medicaid ID at well-child visits. Training and education for providers has been underway, and technical assistance around billing and coding is ongoing.
• Family Planning Waiver: An impact paper on the importance and benefits of publicly funded family planning services was drafted to begin the conversation of implementing a waiver or state plan amendment to provide affordable reproductive health to under-insured and uninsured individuals across the state.

Kansas Strengths & Challenges

Health Equity & Social Determinants of Health (SDoH)/Disparities: When looking at outcomes such as infant mortality, preterm birth, and smoking during pregnancy, we see consistent trends based on race/ethnicity (particularly non-Hispanic black and non-Hispanic white) and socioeconomic factors (particularly Medicaid vs. non-Medicaid). Non-Hispanic Blacks especially show greater risk for worse health and pregnancy related outcomes. For example, Non-Hispanic Blacks have lower prenatal care rates and higher rates of low birthweight infants, and infant mortality.15

In addition to race/ethnicity other social and physical determinants (e.g., insurance type, education level, federal poverty level, special health care needs/disability) can have a critical impact on one’s ability to thrive in their environment. It would not be prudent to look at these variables in isolation, as one often affects another.  For example, people with lower education levels are more likely to live in poverty. According to the 2018-2019 National Survey of Children’s Health (NSCH), households with lower income are more likely to have adults in the household with a high school diploma, GED, or less. Whereas those with higher education levels also have higher household incomes.

Data Source: National Survey of Children’s Health, 2018-2019 Combined, Child and Family Health Measures

According to the 2018-2019 National Survey of Children’s Health (NSCH), families of CSHCN utilize public insurance only at a higher rate than those without special health care needs. The uninsured rate is lower among CSHCN families.

Data Source: National Survey of Children’s Health, 2018-2019 Combined, Child and Family Health Measures

The Annie E. Casey Foundation’s (AECF) KIDS COUNT® Data Book uses 16 indicators to rank each state across four domains: (1) Economic Well-Being, (2) Education, (3) Health, and (4) Family and Community. These represent what children need the most to thrive. The 2021 Data Book presents state profiles with trends (comparing data from 2010 with those from 2019, whenever possible), providing a picture of child well-being prior to the COVID-19 pandemic. Kansas ranked 18th for overall child well-being, 11th in economic well-being, 23rd in education, 25th in health, and 24th in family and community. Every indicator in the economic well-being and family and community domains improved, three of the health indicators and half of the education moved in the right direction.14 The following images are from the Kansas 2021 KIDS COUNT® Profile.

Health coverage is also a critical factor associated with differing health and birth outcomes. According to the US. Census’s Household Pulse Survey (March 3 - March 29, 2021), based on the AECF 2021 KIDS Count Data Book, which provides a sense of the conditions that families endured throughout 2020, in Kansas, one in 10 adults with children in the household (10%) reported a lack of health insurance; one in five adults living in households with children (20%) said they felt down, depressed or hopeless; more than one in 10 households with children (11%) said they had only slight confidence or no confidence at all that they would be able to make their next rent or mortgage payment on time; about one in 12 adults with children (8%) said their household sometimes or always did not have enough to eat in the most recent week; more than one in 10 households (11%) did not always have access to the internet and a computer for educational purposes; nearly four in ten adults (40%) who were planning to take postsecondary classes in the fall of 2020 said they would either take fewer classes than anticipated or cancelled their postsecondary education plans.14 Mothers on Medicaid have a greater risk of worse health outcomes than mothers not on Medicaid.

Kansas Birth Statistics, by Insurance Status, and Year25

While the examples above focus largely on single issues, when SDoH factors overlap, the risk of negative outcomes can grow. Kansas must work to address SDoH across multiple fronts to most effectively create change in the State.

Primary Care Access & Workforce: In 2019, the supply of family practitioners per 100,000 population (18.9) was significantly lower in Kansas than the national average (33.3). In 2019, the supply of obstetricians/gynecologists (7.9) was higher than the national average (5.7). In 2019, the supply of pediatricians (3.1) in Kansas was significantly lower compared to the national average (9.1).12 As of December 2020, there are eighteen (18) counties with a Geographic Primary Care Health Professional Shortage Area (HPSA) designation.

Image Credit: KDHE, Office of Local and Rural Health

Specialty Care Access & Workforce: Access to care has been recognized as a challenge for the maternal and child health population living in both urban and rural geographic areas, but for different reasons. For example, women in rural areas face barriers accessing transportation and getting to providers who may be unavailable in their area. Whereas, women in more densely populated areas, have a wider availability of services yet may not have time off work or the insurance needed to receive services. The CSHCN population often experiences reduced access due to the lack of pediatric specialists in the state, in addition to the other barriers mentioned. In fact, according to the 2018-2019 National Survey of Children’s Health, in Kansas, 27.4% of CSHCN families reported that they had trouble getting specialist care versus 13.0% of non-CSHCN families.5

Estimates derived from national prevalence and 2019 US Census data suggest at least 153,355 or 21.9% of Kansas children have experienced a mental health disorder, and around 34,312 or 4.9% of Kansas children meet the criteria for severe impairment. Over 65% of Kansas youth with major depression do not receive mental health treatment, and only 26.5% of Kansas youth with severe depression receive consistent treatment. Largely rural, Kansas faces severe shortages of medical providers across the state, particularly mental health professionals. Ninety-nine of the 105 counties in Kansas are designated as mental health professional shortage areas, or mental health HPSAs. This shortage leaves nearly 70% of Kansas children with unmet mental health needs.13

Image Credit: KDHE, Office of Local and Rural Health

Due to the shortage of providers, ensuring adequate access to mental health services for Kansas youth will require an innovative approach that increases capacity across a range of medical settings and offers new avenues for care. Kansas is home to more than 700,000 children, all of whom should have access to integrated healthcare. Such integration would require primary care providers (PCPs), including pediatricians, family practice physicians and non-physician PCPs who can screen, diagnose, and treat children and adolescents with uncomplicated mental illness, such as anxiety, depression, and attention-deficit/hyperactivity disorder (ADHD). A reformed model of care would also require the establishment of an expert pediatric mental health care team to provide training, consultation, and support services to PCPs.

Overall, KDHE has recognized that programs and providers are an important part of the landscape and the unique needs of the Kansas MCH population are being addressed throughout the state. The Bureau has been and will continue to be committed to working with local partners to address those unique needs, and to build on the successes at the local and regional levels in improving maternal and child health.

State Health Agency Mandated Priorities – Title V Roles & Responsibilities

Kansas is a state that values young children and families. Over the past decade, significant investments have been made in building a collaborative environment and in supporting at-risk communities to improve child and family health and well-being. The Bureau of Family Health within the Kansas Department of Health and Environment has been a leader in these efforts.

Financial Assistance for CSHCN: Kansas Law mandates financial supports for health care services for CSHCN pursuant to K.S.A. 65-5a01, based on medical and financial eligibility, provided through the Kansas Special Health Care Need Program (KS-SHCN) and core Title V program. KS-SHCN provides this assistance through nine (9) direct assistance programs, referred to as DAPs. The chart below outlines the services available and eligibility for the DAP.

Each of the following DAPs have eligibility criteria and annual maximum assistance amounts. All families who meet medical and financial eligibility for the program can receive support through up to two DAPs each year. More information can be found in the CSHCN Section.

Infant Mortality Reduction: Kansas Title V is a lead partner in convening and facilitating efforts to reduce infant mortality and eliminate disparities in maternal and infant health. Over the past several years, the Title V program has invested in comprehensive approaches to prenatal care and education, tobacco/smoking cessation (before, during, after pregnancy), and pre/early term birth. From concept to reality, the state has worked to integrate initiatives into existing systems to provide the mechanism to achieve current success and future expansion of successful programs. There were 189 infant deaths in 2019 in Kansas, a decrease of 18.2% from 231 infant deaths in 2018. The infant mortality rate for Kansas residents in 2019 was 5.3 infant deaths per 1,000 live births, down 17.2% from 6.4 infant deaths per 1,000 live births in 2018. This meets the Healthy People 2020 target for infant deaths, 6.0 infant deaths per 1,000 live births, and was the lowest infant mortality rate for Kansas residents in the last 20 years (2000-2019). The rate for White non-Hispanic mothers in 2019 was 4.1 deaths per 1,000 live births, a decrease of 14.6% from the rate of 4.8 in 2018. The rate for Black non-Hispanic mothers was 10.7 deaths per 1,000 live births, an increase of 7.0 percent from the rate of 10.0 in 2018. The rate for Hispanic mothers was 6.4 deaths per 1,000 live births, a decrease of 28.9% from the rate of 9.0 in 2018. Infant death rates for non-Hispanic black mothers have consistently remained higher than those of non-Hispanic white and Hispanic mothers for the past twenty years (2000-2019). Rates for Hispanic mothers have been higher than those for White non-Hispanic mothers in most years in the period.2

Maternal Mortality Review: Within the population of women of reproductive age, maternal mortality (death of a woman during pregnancy or up to one year after pregnancy) is an indicator that is monitored by KDHE pursuant to K.S.A. 65-177. Kansas maternal mortality data are closely aligned with national trends, as there are clear patterns that can be identified within the data. The following Kansas women are at greater risk of maternal death and therefore remain target populations for prevention efforts: advanced maternal age (35 years or older); Non-Hispanic black women; and women who have lower levels of education, are unmarried (separated, divorced, widowed, or never married), those that have Medicaid or are uninsured, and live in rural areas. Severe maternal morbidity is also monitored by Title V. It is critical to understand the patterns and contributing factors considering these are situations that result in lifelong challenges or death.

Kansas’ Systems of Care for Underserved & Vulnerable Populations

A primary focus of the Kansas Title V program is to provide ongoing leadership to advancing and improving systems of care for underserved and vulnerable MCH populations. To support this effort, KDHE contracts with local public health departments (independent entities) and Federally Qualified Health Centers (FQHCs) across the state to ensure provision of MCH services within a coordinated, family-centered system.

Aid to Local Funding/Statewide MCH Network: When funds are allocated to external programs, the Bureau maintains contracts for the use of funds in support of MCH priorities. Services are delivered in compliance with Title V legislation and in accordance with the KS MCH Manual: Kansas Health Services Manual (kdheks.gov). The manual provides background on the Title V MCH Block Grant legislation/authority, KS MCH program principles, and service guidance and offers a vast appendix of resources related to practice and national performance measures.

The process with local agencies begins with the development of Grant Application Guidance and Reporting Materials annually in December. Materials are available by mid-January to local agencies applying for Title V funding. Due to the pandemic, KDHE wanted to provide local agencies extra time to complete grant applications. The applications opened December 15 with a due date of March 15. The review process informs funding recommendations and involves external reviewers applying guidance and a scoring matrix, a funding formula based on poverty and population by county/target area, and willingness/ability to comply with grant requirements. Detailed client and service data is required to be collected, aggregate progress reports and affidavits of expenditures are required quarterly, and site visits are conducted to verify compliance with funding requirements and progress. More information about the MCH Aid to Local Program is available online through the Kansas Grant Management System (KGMS) site: https://khap2.kdhe.state.ks.us/KGMS/Default.aspx.

Title V contracts with over 60 local agencies to provide MCH services across the population domains and most local services funded by the Block Grant are delivered by local health departments and safety net clinics (independent entities). These agencies are positioned to provide core public health services in addition to MCH, so the delivery system has the advantages of convenience and comprehensive care. The services delivered by local agencies are designed to address ongoing needs and those identified by the most recent needs assessment. In May 2020 an interactive map of MCH service delivery sites was created to allow community organizations, providers and the public to easily identify and connect to services in their area. Aid to Local (ATL) contract documents and the list of 2020 MCH grantees are included in the Supporting Documents.

Health Equity & Disparities: The agency has ramped up the investment into Health Equity with the creation of a dedicated staff member for health equity and the establishment of the Health Equity Action Team (HEAT). Two Bureau staff participate in the HEAT team and are actively involved in initiatives such as health equity training, hiring practices and data collection.

To address disparities in the maternal and child health population, Title V has taken the following action steps to improve health equity and eliminate disparities:

• Using data to determine where to pilot/target programming based on disparities (e.g., Smoking Cessation pilot sites chosen from the counties with the highest smoking rates)
• Collecting quantitative and qualitative data through focus groups to determine impactful activities to address disparities in health outcomes within black and Hispanic communities.
• Increasing access to prenatal education and service access in communities with demonstrated disparities (Kansas Perinatal Community Collaboratives/Becoming a Mom®)
• Providing culturally appropriate prenatal education (bi-lingual curriculum and instructors)
• Providing culturally appropriate breastfeeding support and resources in communities with demonstrated disparities (e.g., Chocolate Milk Cafes [peer support] Black Breastfeeding Coalition, a Latina Breastfeeding Coalition, Spanish language breastfeeding training for home visitors, increased breastfeeding educators and peer counselors of color)
• Assessing the need for health coverage, transportation, housing, food, education, etc. (e.g., holistic care coordination)
• Exploring and implementing telehealth to increase access to care in rural and underserved areas.
• Including an equity lens on all aspects of the Title V State Action Plan and including specific strategies to combat health inequities.
• Implementing nontraditional community-level outreach (minority and at-risk)
• Assuring gap-filling services for those without insurance/access
  • Expediting Medicaid eligibility for prenatal care coverage
  • Assuring Medicaid reimbursement for perinatal mood and anxiety disorder screening in multiple settings, including the pediatric setting
• Screening for social determinants through local MCH programs
  • Development of a prescreening tool that aligns across MCH programs that includes screening for SDOH, mental health, substance use, IPV, Tobacco use, pregnancy intention
• Development of a health equity learning collaborative that allows local communities to uncover root causes of a health equity issue in their community, this collaborative called the MCH Opportunity Project is currently in cohort 2
• Raising awareness of health disparities with public education campaigns in partnership with the Kansas African American Affairs Commission
• Expanding the Community Baby Shower model focused on safe sleep to integrate smoking cessation, breastfeeding education, behavioral health and referral to services on site; partnering with managed care organizations (MCOs) to align efforts
• Implementing a centralized, web-based data sharing system (DAISEY) that allows for monitoring outcomes and quality improvement along MCH programs; ongoing assessment if local programs are serving those most in need and in line with the Title V purpose
• Implementing a centralized, web-based data tracking system (Community Check Box) that allows monitoring of activities and initiatives focused on health equity and ethnic and racial minorities
• Supporting development among the MCH workforce through provision of health equity and SDoH trainings to the Family Advisory and Maternal and Child Health Councils

Systems of Care for CSHCN: Kansas aims to assess and address needs of all children and youth with special health care needs and their families. KS-SHCN continues to expand the focus of the program to address the needs of families through collaboration, systems integration, and increased statewide capacity. Utilizing quality improvement and evaluation, the program strives for sustainable and systemic changes for the CSHCN population. The Kansas State Plan for CSHCN provides opportunity to further engage with partners in ways to improve the system of care and collaborate more effectively and efficiently.

References

1. Kansas - Wikipedia. https://en.wikipedia.org/wiki/Kansas
2. Oakley D, Crawford G, Savage C. Kansas Annual Summary of Vital Statistics, 2019. Topeka, KS: Kansas Department of Health and Environment, 2020. https://www.kdheks.gov/phi/as/2019_Annual_Summary.pdf
3. U.S. Census Bureau. Bridged-race population estimates, July 1, 2019.
4. U.S. Census Bureau. 2019 American Community Survey 1-Year Estimates. Table DP02. Selected Social Characteristics in the United States. https://data.census.gov/cedsci/table?d=ACS%201-Year%20Estimates%20Data%20Profiles&tid=ACSDP1Y2019.DP02
5. National Survey of Children's Health (NSCH). Combined 2018-2019 NSCH. Data query from the Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health website. www.childhealthdata.org
6. U.S. Census Bureau. 2019 American Community Survey 1-Year Estimates. Table S1602. Limited English-Speaking Households. https://data.census.gov/cedsci/table?q=S1602&g=0400000US20&tid=ACSST1Y2019.S1602
7. U.S. Census Bureau. Poverty Thresholds. https://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty-thresholds.html
8. Columbia University, National Center for Children in Poverty. Kansas Demographics of Low-Income Children. http://www.nccp.org/profiles/KS_profile_6.html
9. U.S. Census Bureau, Small Area Income & Poverty Estimates (SAIPE), 2019. https://www.census.gov/data/datasets/2019/demo/saipe/2019-state-and-county.html
10. U.S. Census Bureau. 2019 American Community Survey 1-Year Estimates. Table S1702. Poverty Status in the Past 12 Months of Families. https://data.census.gov/cedsci/table?q=S1702&g=0400000US20&tid=ACSST1Y2019.S1702
11. U.S. Census Bureau, Small Area Health Insurance Estimates (SAHIE), 2019. https://www.census.gov/data-tools/demo/sahie/#/
12. Bureau of Labor Statistics, Occupational Employment Statistics, Occupational Employment Statistics Query System: https://data.bls.gov/oes/#/home
13. Kaiser Family Foundation, Mental Health Care Health Professional Shortage Areas (HPSAs), as of September 30, 2020. https://www.kff.org/other/state-indicator/mental-health-care-health-professional-shortage-areas-hpsas/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
14. Annie E. Casey Foundation. 2021 KIDS COUNT Data Book. https://www.aecf.org/m/resourcedoc/aecf-2021kidscountdatabook-2021.pdf
15. Annie E. Casey Foundation. KIDS COUNT Data Center. https://datacenter.kidscount.org/
16. Kansas Annual Summary of Vital Statistics, 2019. https://www.kdheks.gov/phi/as/2019_Annual_Summary.pdf
17. Kansas Historical Society. Kansapedia. American Indians in Kansas. https://www.kshs.org/kansapedia/american-indians-in-kansas/17881
18. Credit: Julia Soap, Doctor of Physical Therapy (DPT); Drew Duncan, Screening and Surveillance Unit Director, Bureau of Family Health.
19. U.S. Department of Health and Human Services. Office of Minority Health. Profile: American Indian/Alaska Native. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=62
20. U.S. Census. 2015-2019 American Community Survey 5-Year Narrative Profile. https://www.census.gov/acs/www/data/data-tables-and-tools/narrative-profiles/2019/index.php
21. U.S. Census Bureau. 2015-2019 American Community Survey 5-Year Estimates. My Tribal Area. https://www.census.gov/tribal/?st=20
22. Kansas Health Institute, Kansas Medicaid Primer 2019. Publication number KHI/19-01. www.khi.org/assets/uploads/news/14859/2019_medicaid_primer_r_web.pdf
23. KDHE Division of Health Care Finance, 2019.
24. U.S. Census Bureau. 2019 American Community Survey 1-Year Estimates. Table DP05. ACS Demographic and Housing Estimates. https://data.census.gov/cedsci/table?q=&text=DP05&g=0400000US20&tid=ACSDP1Y2019.DP05
25. KDHE, Bureau of Family Health, Kansas Department of Health and Environment Bureau of Family Health. Title V Outcome Measures and Performance Measures, 2019.