III.E.2.c. State Action Plan Narrative

Maternal Health Application Year

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.

In 2025, $1,009,706 in Title V funds will be allocated across 11 of the 24 local health departments for maternal health initiatives. All local health departments receive Title V core public health funds, and these eleven local health departments have chosen to use the funds for perinatal care coordination and home visiting services.  

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%)

Title V will partner with the Office of Oral Health to disseminate existing resources, specifically the 2024 Maryland Oral Health Resource Guide thare are both available in English and Spanish as well as information about the 2022 Pregnancy Guidance Document.  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 guidance document will be shared with community health workers, home visitors, and obstetric providers.

Furthermore, perinatal care coordinators and home visitors 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. They will also share information about the importance of oral health from the above resources.

While Maryland Title V did not transition the Focus Area 1 to a broader NPM of well-woman 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 2025.

 

 

Women’s Health

The Secretary of Health has prioritized women’s health during FY2025. MCHB and Title V staff developed a Women’s Health Action Plan that focuses on 6 main goals:

1. Protect reproductive rights and expand access to reproductive health services.
2. Advance birth equity, with a focus on Black maternal and infant health, through the perinatal continuum.
3. Support behavioral health needs throughout the life course.
4. Improve access to high quality somatic services throughout the life course.
5. Increase place-based approaches to promote health and prevent disease.
6. Expand, support, and diversify the perinatal workforce.

 

The Women’s Health Action Plan, which is a Department-wide plan, led primarily by Title V staff, launched during FY 2024. Overall, in FY 2025, Title V staff will work to align Title V State Action Plan with the Women’s Health Action Plan along with other State Plan such as the Moore-Miller 2024 State Plan, the 2024 State Health Improvement Plan: Building a Healthier Maryland, and the MDH Public Health Strategic Plan.

Furthermore, Title V staff will take the findings from the Title V needs Assessment and develop an implementation plan for both the Women’s Health Action Plan as well as the Title V Action Plan.

For Strategic Priority Area #1, the Department has partnered with Upstream USA to increase equitable access to patient-centered contraceptive care in primary care settings across Maryland through free training and technical assistance. In FY 2025, MCHB will facilitate recruitment of federally qualified health centers (FQHCs), health systems, and higher education institutions into the Upstream program. MCHB staff will also provide support implementation with the four sites that have signed MOUs with Upstream.

The state-funded Maryland Abortion and Reproductive Clinical Health (MARCH) training program aims to increase the number and type of trained abortion providers in Maryland. In FY 2025, the University of Maryland, Baltimore (UMB) will use recent needs assessment findings to guide its ongoing strategy and design. MCHB will support UMB to finalize the training curriculum, acquire mobile simulation units, initiate training for the first cohort of learners, and establish partnerships with additional training sites.

Increasing the number of well-woman visits

To increase the number of well-woman visits from a baseline of 73 percent (2020; BRFSS) to over 78 percent by 2025.

The Title V team will continue to work on increasing the number of well-woman visits through partnership. The Maryland Family Planning Program (MFPP) will not only provide family planning services, but also navigate social needs identified through the visits, and link to other primary care providers.   The Maryland Family Planning Program is funded through federal Title X funds and general state funds, which is used as a Title V match.

In FY 2024 the MFPP conducted a statewide Needs Assessment that identified priority service areas for reproductive and sexual health in Maryland. Among those were two counties not previously served by Title X. The program established relationships with health centers in those counties and offered funding opportunities for up to three agencies. In FY 2025 the MFPP will add new sites in Talbot, Allegany and Cecil Counties to its existing 63 sites across Maryland. With the new sites, there will now be a Title X clinic in each of the 24 jurisdictions, advancing the availability and accessibility of reproductive health services across the state.

During the Maryland General Assembly 2022 Legislative Session, House Bill 1080 was passed that required Medicaid to provide comprehensive coverage for pregnant and postpartum individuals, regardless of immigration status. This coverage is available to individuals with family incomes up to 250% of the federal poverty level (FPL) for pregnancy, delivery and four months immediately following the end of the birthing individual’s pregnancy. This coverage includes dental care as well as comprehensive medical care, including mental health. Coverage became effective starting July 1, 2023. As of April 2024, More than 7,300 people are enrolled and now have access to critical health care services and support. 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.

For FY 2025, Title V staff will focus on increasing linkages to care, specifically through expanding the Maryland Prenatal Risk Assessment (MPRA) and Postpartum Infant Maternal Referral (PIMR) Forms. Maryland Department of Health received additional HRSA funding called the Integrated Maternal Health Services Grant. Through the additional funding, Title V staff will increase referrals to community-based services and local health departments by developing the electronic versions of the MPRA and PIMR forms in the Regional Health Information Exchange, CRISP. Title V staff will work directly with the local health departments on the Eastern Shore and Prince George’s County, prenatal clinics, and birthing hospitals.

 

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. Title V funding for Local Health Departments is mandated by House Bill 314, Laws of 1995.  Local Health Departments will be able to choose services that align with their local needs and with the State Action Plan, including providing perinatal care coordination services. Local Health Departments will continue to link pregnant people who are referred through the Maryland Prenatal Risk Assessment and PIMR. Title V funds supplement perinatal care coordination through general funds through the Babies Born Healthy and Thrive by Three funds.

 

Focus Area 2: Substance use prevention

Substance use prevention and links to care through 1) percent of women who smoke during pregnancy (NPM 14.1), 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). 

 

Referrals to Maryland Quitline

For Fiscal Year 2025, 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 FY 2025, 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

Title V will continue to partner with Medicaid and the Overdose Data to Action (OD2A) funded through the Centers for Disease Control and Prevention to improve linkages to care, specifically conducting relationship building activities. Local health departments will visit local birthing hospitals to educate and inform clinical staff on utilizing the Postpartum Infant and Maternal Referral (PIMR) form. Virtual and in-person visits will encourage increased utilization of the form and increase the number of life saving referrals provided for postpartum people who use drugs. 

 

Develop and Start a Perinatal Mental Health Training Hub

In addition, Title V and the HRSA Integrated Maternal Health Services 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.

 

Provide support to providers through Maryland Addiction Counseling Service (MACS) for MOM

MACS for MOM, which is operated by the University of Maryland School of Medicine provides training and support to providers across the state. In FY 2024, 160 unique providers participated in the tele-ECHO clinics that were run by MACS for MOM. In 2025, MACs for MOM plans to continue with the tele-ECHO clinics.  In FY 2024, the administration from MACS for MOM was transferred from the Maryland Medicaid team to the Title V team to allow for a whole women’s health approach.  State general funds will support MACS for MOM in FY 2025.

During FY 2024, the Office of Gender Specific Services (GSS) at the Behavioral Health Administration moved to the Prevention and Health Promotion Administration/Maternal and Child Health Bureau.  This integration provided alignment with the women’s health initiatives and will create an opportunity to expand services while maintaining support for existing programs.

Programs under the Office of GSS include:

• Residential treatment services for pregnant women and women with dependent children.
• Recovery Programs for Pregnant Women and Women with Children that includes recovery houses, transitional housing, for pregnant women and their children as well as men with children recovery house.
• The Strengthening Families in Recovery grant program.
• Substance Abuse and Treatment Services (SATS) Program that integrates child welfare and substance use disorder treatment services.
• Sobriety Treatment and Recovery Teams (START) Program  that works with child welfare agencies to provide peer mentor support, quick access to intensive SUD treatment, intensive case management in a family centered approach.
• Jail-based services for women including for intensive outpatient treatment programs and childcare during residential treatment.

 

In FY25, Bureau staff, including Title V staff will transition the office programs and services to the Bureau as well as further develop new strategies for Goal 3 of the Women’s Health Action Plan. Furthermore, Title V staff will help align CDC’s Overdose Data 2 Action efforts with the newly transferred programs.

 

Focus Area 3: Disparities in Maternal Mortality and Morbidity

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%.

During FY24, Title V staff supported the passage of the Maternal Health Act (Legislation of SB 1059) to establish requirements that local health departments and health care providers complete the prenatal risk assessment and the postpartum infant maternal referral form to increase linkages to community-based services. Furthermore, the Department will develop a Maryland Report Card for Birthing Facilities. In FY25, Title V staff will work towards implementing the Maternal Health Act. The Bureau will prioritize the Eastern Shore and Prince George’s County to implement the digitization of the Maryland Prenatal Risk Assessment and the Postpartum Infant Maternal Referral Form.

 

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, 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, and 3) looking for sustainable funding for essential supportive services by partnering with Medicaid.

 

Maternal Health Innovation Program

In FY25, the Title V Program will continue to work with the Maternal Health Innovation Program, also called “MDMOM,” by Johns Hopkins University (JHU), by monitoring the maternal health improvement Strategic Plan (the Strategic Plan). MDMOM was successfully awarded a second five-year grant in September 2023. During FY24, Title V worked with the Task Force to explore how the Strategic Plan could be implemented. In collaboration with JHU, the Task Force developed a map of maternal health service providers in Maryland. The map was launched publicly in March 2024.

The Task Force will also revise the Strategic Plan to better reflect reproductive justice and actions to promote health equity. The current Strategic Plan 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 FY25 the Task Force will engage in a facilitated retreat to support the ideation and development of revisions. The Department will assist in planning logistics and coordinating the synthesis of the draft revisions, to be submitted to HRSA in Fall 2024.

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 due to high 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 FY22, four home visiting sites in priority jurisdictions with elevated SMM events were selected after an open bid procurement. During FY25, Title V will continue to implement the grant funds and the SIHIS home visiting expansion will begin their final year of SIHIS home visiting expansion services.

All home visiting sites have struggled with recruiting and maintaining their home visiting workforce since FY22. Each site has implemented a variety of strategies to address this, including contracting with temporary staffing agencies, reallocating current staff, providing competitive compensation packages, and recruiting through multiple channels. MDH continues to work with grantees and our partners in MIECHV to provide technical assistance and support. Below is a summary of the SIHIS home visiting sites and FY25 goals:

The Montgomery County Health Department will continue to expand the Babies Born Healthy (BBH) program using the March of Dimes Becoming Mom (BAM) curriculum. In FY22 and FY 2023 Montgomery County enrolled 73 individuals, and over the course of FY 2025 will continue to serve approximately 40 patients supported through the SIHIS expansion, in addition to their ongoing enrollments under BBH. 

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. Since receiving SIHIS funding the program has enrolled 12 families and will strive to maintain at least 85% of its enrollment capacity in FY25. Washington County’s program is unique from the other three sites in that it has the longest potential enrollment for a family (from prenatal through the child’s fifth birthday). The overall number of families receiving services may not change drastically from year to year if families are continuously participating in the program.   

The Family Tree will continue to expand home visiting services in Baltimore City through the Parents as Teachers (PAT) model. In FY25 the Family Tree will leverage new staff members to achieve their initial target of enrolling 40 families annually into this model.  

In FY25, Baltimore Healthy Start (BHS) will shift to partnering with Total Health Care to offer dyad care services, in addition to providing 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. As of December 2023, BHS was actively serving 24 families (including both those newly enrolled and those continuing services). Priority in FY25 will be placed on increasing the number of families actively served to 40.

Funds will be used 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 FY22, and continues to successfully provide services at their Mead Building location in Baltimore City. In FY23 through a separate procurement, Centering Healthcare Institute, Inc. was selected to provide implementation support of CenteringPregnancy to four additional sites. In FY25 additional funds will be added to increase the amount of sites by three sites for a total of up to 10 sites. A priority will be placed on recruiting sites in jurisdictions that experience higher rates of severe maternal morbidity, and rural jurisdictions.

The remaining SIHIS funds will 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 FY25, 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 FY25, 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. The MDPQC began work to implement a new bundle focused on reducing obstetric hemorrhage in July 2023, and will continue this work in FY25. 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.

Furthermore, the department received funding in Fall 2023 to support capacity building for birthing hospital and clinic staff participating in the MDPQC. In FY25 the department will partner with the Bloom Collective to deliver training and technical assistance to healthcare providers to center black birthing people in quality improvement efforts.

Maryland will also participate in the Health and Human Services’ Postpartum Collaborative. The stated vision of the collaborative is to change the trajectory of maternal morbidity and mortality to improve the lives of families in the participating states. As part of the Postpartum Collaborative, Title V will partner with a healthcare system to pilot interventions to address avoidable readmissions due to hypertensive disorders of pregnancy.

 

Maternal Mortality Review Program

During FY25, 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.

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 FY24, the program completed its first review of maternal death cases with its expanded membership.

In FY25, 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), and conduct 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. The program will continue to work with the existing MMRT to implement the new Maternal Mortality Review Information Application format of case review, and explore programs to support member wellbeing and self-care.

Translation of MMRT recommendations is a priority for the program, with an emphasis on supporting local-level efforts to prevent maternal mortality and improve maternal health. The program hosted its first ever statewide summit on maternal mortality in May 2024, which brought together diverse stakeholders to share the latest data and catalyze actions. In FY25, the program will continue to refine its dissemination strategy and begin planning to implement projects that address recommendations developed by the MMRT and MMR Stakeholder Group.

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.

Increasing the proportion of people who attend their postpartum visit

Title V will participate in the Health and Human Services Postpartum Collaborative, where Maryland is one of six states to participate to address the leading cause of postpartum readmissions. Title V will also partner with the Maryland, Infant, Early Childhood Home Visiting Program to expand evidence-based perinatal home visiting services from 10 to 16 jurisdictions. Title V leads efforts to expand referrals to local health departments and community-based services through digitizing the Postpartum Infant Maternal Referral Forms. Title V will continue to partner with Medicaid to promote the postpartum expansion and the Healthy Babies Equity Act, which provides Medicaid coverage for pregnant individuals regardless of their immigration status.

Focus on Reproductive Health Services

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 ensure that individuals can make informed choices about their reproductive health and plan their families according to their needs and circumstances.

During FY24, the program had undergone a Statewide Family Planning Needs Assessment, and in FY25, the program will implement several of the recommendations such as an updated, needs-based funding formula; expansion of Title X/Family Planning clinics in Western Maryland and the Eastern Shore; a renewed focus on training and technical assistance; and strategic initiatives to increase access to youth and Spanish-speaking individuals. Furthermore, the program will include a focus on addressing clients’ health needs in order to achieve their reproductive health goals, including improving hypertension screening and management. The Maryland Family Planning Program remains committed to providing support to subrecipients as they continue innovative health practices to serve their communities.

 

Increasing Capacity for Abortion Clinical Training

The Maryland Abortion and Reproductive Clinical Health (MARCH) training program, which is state-funded, will incorporate findings from a recently completed needs assessment to inform the program’s ongoing strategy and design. MARCH’s overall goals are to increase the number and type of trained abortion providers in MD. In the first quarter of FY25, MARCH’s implementing partner, the University of Maryland, Baltimore, will finalize the training curriculum and student clinical placement track, receive procured mobile simulation units, and begin training the first cohort of existing clinician learners.