Maryland Title V identifies the priority for women’s maternal health as ensuring that birthing people are in optimal health before, during, and after pregnancy.  Overall in FY 2023, Title V focused on women’s health and continued to take a life course approach to understand and address the range of health needs of girls and women across the lifespan.To this end, in FY 2024, Title V will employ the following strategies to improve maternal health outcomes statewide:

 

Focus Area 1:  Oral health: To increase the number of pregnant people receiving preventive dental visits from a baseline of 28% (2019) to over 36% by 2025 (Healthy People 2030 Target: 45%)

 

The Office of Oral Health (OOH) will leverage its established partnership with the Maryland section of the American Congress of Obstetricians and

Gynecologists (ACOG) to disseminate Oral Health During Pregnancy. The ACOG will issue Practice Guidance for Maryland’s Prenatal and Dental Providers through local health departments and other providers. The practice guidance contains essential information on oral health during pregnancy, including background on oral conditions during pregnancy, myths and facts about the safety of oral health care for pregnant women, pharmacological considerations for dental care for pregnant women, and detailed practice guidance for prenatal providers. The document also includes a variety of associated resources for use in practices and for patients. In addition, the OOH will also provide detailed information on how to apply the document’s guidance in their practices. The Office of Oral Health team will conduct outreach to providers to assist them in establishing local referral networks for their pregnant patients by providing the OOH Resource Guide that contains low cost dental resources in each county,  with the goal of increasing access to oral health care for this population.  In FY 23, the OOH provided the publication to 630 OB/GYN offices across the state.

 

Maternal and Child Health Care Coordination at the Local Health Department will continue linking pregnant people who are referred through the Maryland Prenatal Risk Assessment to Oral Health providers as part of their care coordination.

 

While Maryland Title V did not transition the Focus Area 1 to a broader NPM of well women visits during FY2023 as the Title V application operates on a five year cycle, Maryland Title V would like to share some of its future plans that highlights women’s health during FY 2024. The Secretary of Health has prioritized women’s health during FY2023. MCHB and Title V recognizes that as it relates to women’s health there are four main strategic opportunities:

 

1. Help people realize their sexual and reproductive health goals. People need access to accurate information and to safe, affordable, culturally-congruent reproductive and sexual health services. People must be informed and empowered to make their own choices including whether or not  to have children or not have children. The Maryland Department of Health administers the Maryland Family Planning Program that oversees over 60 clinics across the state to help support the life and health goals of all Marylanders. The Program is undergoing a Statewide needs assessment to better understand access needs, particularly for impacted communities.

 

2. Recognize abortion access as fundamentally a health issue.  The American College of Obstetrics and Gynecology,[1] Health and Human Services,[2] the American Academy of Family Physicians[3] recognize that access to abortion is essential to health and healthcare.   Owing to a wide range of factors (e.g. interpersonal racism, distance from health care institutions, health insurance status, employment benefits), Black and Indigenous people, immigrants, and rural residents have comparatively limited access to abortion care and other reproductive health services.[4]  When people can’t prevent or terminate an unwanted or medically risky pregnancy, can’t easily access prenatal care, and live far away from a birthing hospital, clinicians struggle to prevent tragedies and people’s health suffer. The Department is implementing the Abortion Clinical Care Training Program. The Program will help expand the number of healthcare professionals with abortion care training, increase the racial and ethnic diversity among healthcare professionals with abortion care education, and support the identification of clinical sites in need of training to increase access to safe abortion care, particularly in marginalized communities.

 

3. Eradicate HPV-associated cancers in women and men. Maryland has the opportunity to eradicate HPV-associated cancers in women and men. Yet too many people are not getting a safe and effective vaccine that prevents six different cancers. In Maryland, approximately 73.8% of girls under age 18 are fully vaccinated against HPV-associated cancers. Nationally, approximately 27% of men and 53.6% of women ages 18-26 are vaccinated.  In rural communities, HPV vaccination rates are low, yet incidence and mortality rates of HPV-associated cancers are high. The Maryland Cancer Collaborative is working with the Maryland Chapter of the American Academy of Pediatrics to increase the first dose HPV vaccine rate at 45 provider offices.

 

 

4. Leverage Maryland's unique finance healthcare model, the Total Cost of Care, to evolve our current systems of care and improve health outcomes and eliminate health disparities. Maryland’s Total Cost of Care (TCOC) Program aims to improve quality of care, save healthcare costs, and improve population health. As part of the TCOC, the Maryland Primary Care Program (MDPCP)  incentivizes primary care practices and Federally Qualified Health Centers in Maryland to offer advanced primary care services to their patients. While MDPCP currently focuses on the Medicare population, the Program plans to  focus on Medicaid recipients in the future. In addition, the Statewide Integrated Health Improvement Strategy (SIHIS) focuses on population health goals such as decreasing Severe Maternal Morbidity and disparities as well as focus on diabetes and opioid use disorder.

Potential Future Objective 1: To increase the number of well-woman visits from a baseline of 73% (2020; BRFSS) to over 78% by 2025.

 

If the broader national performance measure is approved, the Title V team will continue to work on increasing the number of well-woman visits through partnership. The Title V team and the Maryland Family Planning Program (MFPP) will expand telehealth services in family planning and preventive care services.  Maryland Family Planning Services will not only provide family planning services, but also navigate social needs identified through the visits, and link to other primary care providers.  For the telehealth expansion, the MFPP will work with 11 local health departments including Baltimore City, Calvert, Carroll, Dorchester, Garrett, Harford, Howard, Prince George’s, Somerset, St. Mary’s, and Worcester  and three non-profit organizations. These efforts promote the goal to increase well women visits as these visits provide preventive care and provide further coordination and referrals to comprehensive primary care visits. During FY2023, the team will begin by assessing existing telehealth resources in local health department family planning sites, identifying needs, barriers and opportunities to enhance services. The collected data will be used to plan and implement a virtual telehealth training and technical assistance program for participating sites. After the training and technical assistance program, MDH will disseminate a comprehensive telehealth toolkit to the 62 MFPP sites, 24 local health departments and all family planning service sites in Maryland.

 

 

During the Maryland General Assembly 2021 Legislative Session, Senate Bill 923 was passed that required Medicaid to extend coverage for eligible pregnant individuals with family incomes up to 250% of the federal poverty level (FPL) for one year immediately following the end of the birthing individual’s pregnancy. This coverage would include dental care as well as comprehensive medical care.  The extended coverage became effective starting April 1, 2022. Title V staff will continue to work with Maryland families to inform them about the extension of the coverage during provision of services such as care coordination and home visiting.

 

 

In addition for FY2024, Title V staff will focus on increasing linkages to care, specifically through expanding the Postpartum Infant Maternal Referral Form (PIMR). During FY21 and 22, Title V staff released a PIMR best practices form that reviewed the process of the PIMR. The best practices document explained the purpose of the form, including referring mothers and infants who need additional support and information on community-based services at the local health departments. During the past year, Title V staff piloted the electronic PIMR form in one jurisdictionjurisidction.  During the next year, Title V staff will focus on expanding the electronic PIMR through the Regional Information Health Exchange, CRISP.

 

Care Coordination

 

Title V staff will continue to improve the quality and expand care coordination at the Local Health Departments to link pregnant and postpartum people to navigate their social needs and to navigate primary care. In FY2022, Title V allowed funding for Local Health Departments, which is mandated by House Bill 314, Laws of 1995 that the Federal Title V Maternal Child Health Block grant must go towards the local health department. Local Health Departments will continue linking pregnant people who are referred through the Maryland Prenatal Risk Assessment  and PIMR. Title V has aligned care coordination through the Babies Born Healthy Program, an initiative focused on perinatal care coordination. 

 

 

Focus Area 2: Substance use prevention and linkages to care through 1) NPM 14.1, percent of women who smoke during pregnancy and 2) the state performance measure (SPM 1) of Overdose Mortality Rate for women, ages 15-49.

 

Objective 1 for Focus Area 2: To increase the number of women who abstain from smoking tobacco during pregnancy from a baseline of 95.3% (2019) to 96.3% or more (Healthy People 2030). 

 

Smoking During Pregnancy

Referrals to Maryland QuitLine

For Fiscal Year 2023, Title V will continue and strengthen the partnership with MDH’s Center for Tobacco Control and Prevention.  Specifically, Title V will work with local health departments for care coordination and connect individuals who smoke tobacco to the QuitLine or local health department tobacco cessation programs. QuitLine Coaches use cognitive behavioral coaching and practical skill-building to reinforce effective coping strategies, help the participant manage stress, and build self-efficacy. The QuitLine is a free service to all Maryland residents age 13 and older.  Title V will also collaborate with the Center for Tobacco Control and Prevention to update a tobacco cessation toolkit for OB/GYN providers.

 

In FY2023, the Maryland Family Planning Program will continue to focus on expanding SBIRT (Screening, Brief Interventions, and Referrals to Treatment) throughout their 62 service sites across Maryland. In addition, the program will focus on improving partnerships between substance use disorder clinics and family planning clinics particularly in Western and Northern Maryland.

 

 

Objective 2 for Focus Area 2: To decrease the overdose mortality rate for women, ages 15-49 from 24.1 per 100,000 to 22.9 per 100,000 by 2025.

 

Improve Linkages to Care through Overdose Data to Action

Title V will continue to partner with Medicaid and the Overdose Data to Action (OD2A) funded under Centers for Disease Control and Prevention to improve linkages to care, specifically implementing an electronic version of the Prenatal Risk Assessment (ePRA). During the past year, a pilot project was implemented,  the feasibility of implementing an ePRA statewide to increase the number of prenatal clinics referring clients to local health departments for care coordination. During FFY24, Title V staff, in partnership with Medicaid, will begin the expansion of the ePRA statewide. This work will be informed by the lessons learned during the pilot projects in FY22. In addition, Title V will partner with OD2A to expand implementation of an electronic version of  the postpartum infant maternal referral form (PIMR), that is used to link birthing people and infants to care coordination at local health departments, statewide. Title V will partner with the State’s Health Information Exchange (HIE), called CRISP, to achieve this.

 

In addition, Title V and OD2A will partner to implement  a statewide Perinatal Mental Health Training Hub. The selected vendor will coordinate Hub activities, with the goal of increasing and developing the Perinatal Mental and Behavioral Health workforce in Maryland, to increase linkages to care for pregnant and postpartum people experiencing Perinatal Mood and Anxiety Disorders, and substance use disorder. The vendor will engage with a cohort of public health professionals, including providers of psychotherapy, psychopharmacology professionals, and affiliated professionals such as community health workers, doulas, and peer support specialists, who serve the perinatal population in the target jurisdictions. The applicant will provide opportunities for interprofessional and peer-learning opportunities related to perinatal mental and behavioral health.

 

 

 

Title V will continue to partner with Maryland Medicaid on the Maternal Opioid Misuse Model. Title V staff will continue to serve on the MOM model advisory council. The MOM model advisory council provides input into the model and how to further expand the model in the State. In addition, the Advisory Council will provide input in the partnership with the Maryland Addiction Consult Services.

 

 

Focus Area 3: Reduce rates and eliminate disparities in Maternal mortality and morbidity with the state performance measure of reducing severe maternal morbidity rates that aligns with the Statewide Integrated Health Improvement Strategy.

 

Objective 1 for Focus Area 3: By 2026, reduce the Severe Maternal Morbidity Rate from a baseline of 242.5 per 10,000 delivery hospitalizations to 197.1 per 10,000 delivery hospitalizations and decrease disparities between Black to White SMM rates by at least 20% .

 

Statewide Integrated Health Improvement Strategy  (Severe Maternal Morbidity)

Overall, Focus Area 3 is based on the Statewide Integrated Health Improvement Strategy goals. Through an agreement with the Centers for Medicare and Medicaid Innovation (CMMI), the aim of SIHIS is to advance hospital quality, care transformation across the health care system, and population health.  The last goal, total population health, has three domains:  diabetes, opioids, and maternal and child health.  The maternal and child health goal has two specific outcomes of interest: severe maternal morbidity and childhood asthma.  CMMI approved the State’s strategy proposal on March 17, 2021.

 

Overall, as Title V staff will focus on 1) incorporating equity principles into practice either by partnering and working with more community based organizations 2) shifting committee structures to include people with lived experiences 3) looking for sustainable funding for essential supportive services by partnering with Medicaid.

 

 

Maternal Health Innovation Program

In Fiscal Year 2024, the Title V Program will continue to work with the Maternal Health Innovation Program, also called “MDMOM,” by Johns Hopkins University, by monitoring the maternal health improvement Strategic Plan (the Strategic Plan). During FY2023, Title V worked with the Task Force to explore how the Strategic Plan could be implemented. The Task Force recommended developing a survey of providers who provide birthing services to individuals in the state. This will help the Task Force better understand the landscape of providers, and identify areas where there are gaps in types of services. The survey will also help the Task Force better connect providers across Maryland. In December 2022 the Department drafted an initial survey, and received feedback from the Task Force members in January 2023. The survey will be implemented among Task Force members’ networks in Spring 2023. In FY2024, the Department will work with the Task Force and the contracted Equity Advisor to develop an interactive visualization of the survey results. This is anticipated to be shared publicly at the end of calendar year 2024.

The Task Force will also continue to hone the Strategic Plan to better promote health equity. The Task Force focuses on five goals: 1) promote equity and mobilize against racism in maternal health, 2) achieve maternal health (preconception, prenatal and birth, postpartum and inter-partum periods) using the life course models to support Maryland mothers through advocacy and implementation of policies, 3) improve resiliency for birthing people, families and communities that acknowledge the importance of relationships and social determinants of health for an optimal quality of life, 4) improve access to and utilization of data to make informed decisions, and 5) develop a maternal health workforce that will be available, accessible, and culturally relevant and based on principles of racial equity and justice. In FY2023 the Task Force will begin updating the Strategic plan objectives and activities using an equity-centered framework[5]. In FY2024, members will finalize their updates to the Strategic Plan, and the Department will assist with preparing an addendum to be included in the published document. 

.

Statewide Integrated Health Improvement Strategy Funds

As Maternal and Child Health was identified as the third domain within population health, the Health Service Cost Review Commission approved an additional $40 million dollars over four years to meet the SIHIS Maternal and Child Health goals.  The majority (80%) of the funds goes towards Medicaid to increase linkages to care for birthing people with opioid use disorder, reimburse for doula/birth worker support services, and expand group based prenatal care and maternal and infant home visiting. These are services that provide additional support for the most impacted populations and communities. Through partnership with Medicaid, these services can be more sustainable beyond the SIHIS grant fund periods. 

 

A portion of the MCH SIHIS funds went toward grant funds to allow expansion of promising practice programs. For example, while Nurse Family Partnerships and Healthy Families America are the two evidence-based models supported by Medicaid reimbursement, these models are prohibitive in jurisdictions where they have not already implemented the model. The reason is due to start-up costs. For example, starting a Nurse Family Partnership Home visiting program may cost more than $1 million dollars and maintaining fidelity to this model incurs high ongoing costs.  During FY 2022, four home visiting sites in priority jurisdictions with elevated SMM events were selected after an open bid procurement. During FY2024, Title V will continue to implement the grant funds and the SIHIS home visiting expansion will begin option year two of SIHIS home visiting expansion services. Below is a summary of the SIHIS home visiting sites: :

 

Montgomery County Health Department will continue to expand the Babies Born Healthy (BBH) program using the March of Dimes Becoming Mom (BAM) curriculum. BAM improves maternal knowledge through a community-based collaborative model of care, prenatal education and quality prenatal care. BBH serves high-risk pregnant people beginning at any stage in their pregnancy and following the mother and infant until the child turns six months of age.

 

Washington County Health Department will continue to expand existing home visiting services through the local program affiliate of Healthy Families America. The program offers services to families starting prenatally and continuing through the child’s fifth birthday.

 

The Family Tree will continue to expand home visiting services in Baltimore City through the Parents as Teachers (PAT) model. Home visitors make regular visits from prenatal through kindergarten age. The PAT curriculum focuses on mental health, nutrition, maternal depression, substance use and domestic violence.

 

Baltimore Healthy Start (BHS) will  continue to partner with Chase Braxton Glen Burnie Health Center to expand home visiting services to postpartum women in Anne Arundel County. The program uses the Great Kids curriculum, designed for home visits beginning in the gestational stage of pregnancy. Families are offered standard BHS case management and care coordination services through the Chase Brexton-based Medication Assisted Treatment for Substance Use Disorder program.

 

 To expand CenteringPregnancy, an evidence-based model group

for prenatal care that brings patients out of the exam room and into a group setting where they learn from their provider and each other. Mercy Health Foundation  was selected as a site to implement the CenteringPregnancy Model during FY2022, and continues to successfully provide services at their Mead Building location in Baltimore City.  In FY2023 through a separate procurement, Centering Healthcare Institute, Inc. was selected to provide implementation support of CenteringPregnancy to four (4) additional sites. In FY2024 additional funds will be added to increase the amount of sites by three sites for a total of seven (7) sites

 

The remaining SIHIS funds  go towards public health services to expand asthma home visiting, promising practice and evidence based home visiting, as well as expanding group prenatal care for birthing people, regardless of payor. During FY2024, the Title V program and Maternal and Child Health staff will provide technical support to the expansion programs identified through SIHIS.

 

Maryland Perinatal Neonatal Quality Collaborative

The Maryland Perinatal Neonatal Quality Collaborative (MDPQC) is focused on addressing maternal hypertension and neonatal antibiotic stewardship. For FY2023, the MDPQC will focus on sustained implementation of quality improvement initiatives, which will include identifying barriers, assisting low performers, and continuing regular check-in calls, learning  events, and data reporting. An in-person learning event is scheduled for Summer 2022 to provide updates and invite high performers to share best practices and lessons learned. The effectiveness of the collaborative will also be assessed at the midpoint of each initiative, with the Steering Committee and  participating hospitals providing feedback, and a root-cause analysis will be conducted for any under-performing measures, as needed. The MDPQC will continue to heavily focus on health disparities, and will push out data-driven improvement activities and resources to promote health equity.

 

Maternal Mortality Review Program

During Fiscal Year 2024, the Maternal Mortality Review Program (the Program) will continue to conduct de-identified, confidential case reviews for all pregnancy-associated deaths to identify factors contributing to these deaths. In FY23, the Program successfully bidded and awarded a contract for a new administrative vendor. In FY2024, the Program will continue to build on the new vendor’s success in establishing more efficient access to medical records, including expanding access to electronic health records.The vendor is also working closely with the Program to request and receive additional non-clinical and social records (i.e. information from local health department care coordination offices) as well as interviews with close family members or contacts. This information will provide increased detail and context for each case that cannot be obtained in  the medical records. 

 

Through the support from the Centers for Disease Control and Prevention Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) program, Maryland moved  towards a multi-disciplinary review team in FY23 instead of a predominantly physician-led, medical review team to conduct comprehensive case reviews in line with the national best practices.

 

In July 2022 the Program released a call for applications to seek additional members to join the Maternal Mortality Review Team (MMRT). We specifically sought members with experience in public health, population health, community birth work, or experiences that would better reflect the experiences of people most impacted by maternal mortality. In Fall 2022 we successfully seated 17 new members, in addition to 16 returning members from the earlier MMR committee.

 

In FY2024, the Program will continue to recruit for positions that were not filled in FY2023. These include an individual who works with pregnant or postpartum individuals and have expertise in Clinical Social Work, Community Doula Work, Community Birth Work, provision of behavioral health services, or social services such as housing or food insecurity. The Program will also continue to work with the existing MMRT to implement the new MMRIA-informed format of case review, and explore programs to support member wellbeing and self-care.

 

The Maternal Mortality Stakeholder Group will continue to review the findings and recommendations in the annual Maternal Mortality Review Report, examining issues resulting in disparities, and identifying new recommendations with a focus on disparities in maternal deaths. These findings will inform the Maternal Health Improvement Program Task Force as the implementers of the Maryland Strategic Plan.

Maryland Family Planning Program

The Maryland Family Planning  Program will continue to promote optimal sexual and reproductive health outcomes for men, women and families by improving  access to breast and cervical cancer screening, prevention and treatment of sexually transmitted infections, HIV testing and prevention education, infertility and preconception health services, health education and counseling, and referrals to community resources.  This program provides access to affordable, broad range of family planning methods to assist individuals with their reproductive life plan, which includes postponing, preventing and achieving pregnancy. a To increase accessibility, the program plans to sustain and expand gains made with their FY23 telehealth Expansion Project. Through training and technical assistance MFPP increased telehealth visits by 37% in FY23. In FY24, the Maryland Family Planning Program will also evaluate  SBIRT (Screening, Brief Interventions, and Referrals to Treatment) initiatives implemented in FY23 to improve linkage to substance use disorder treatment and assistance. n addition, the program will continue improving partnerships between substance use disorder clinics and family planning clinics particularly in Western and Northern Maryland. The program’s statewide Needs Assessment will provide an opportunity to learn more about the reproductive health gaps among those with substance use disorders.  Additional FY24 goals include a focus on addressing clients health needs in order to achieve their reproductive health goals, including improving hypertension screening and management. As all sites have reopened post-COVID, The Maryland Family Planning Program remains committed to providing support to subrecipients as they continue innovative health practices to serve their communities.

 

 

[1] ACOG. Facts are Important: Abortion is HealthCare. https://www.acog.org/advocacy/facts-are-important/abortion-is-healthcare Accessed 1 June 2023

[2] HHS. Know Your Rights: Reproductive Health Care. https://www.hhs.gov/about/news/2022/06/25/know-your-rights-reproductive-health-care.html. Accessed 1 June 2023

[3] AAFP. Reproductive and Maternity Health Services. https://www.aafp.org/about/policies/all/reproductive-maternity-health-services.html#:~:text=The%20American%20Academy%20of%20Family,nonevidence%2Dbased%20restrictions%20on%20medical. 1 June 2023

[4] Roberts, D. Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. New York: Vintage, 2014.

[5] https://pubmed.ncbi.nlm.nih.gov/35476759/