HRSA identifies five key strategic priority goals for perinatal and infant’s health, to include: 1) ensuring that higher risk mothers and newborns delivery at hospitals that are able to provide proper care; 2) increasing the number of infants who are breastfed and those who are exclusively breastfed through 6 months; 3) increasing the number of infants placed to sleep on their backs; 4) increasing the number of children who receive a developmental screening; and 5) increasing the number of children who are adequately ensured.
The state of Maryland identifies the objective for this population as improving perinatal and infant health in Maryland by reducing disparities.
For the 2021-2025 Five-Year Action Plan, Needs Assessment Steering Committee selected three NPMs related to perinatal and infant’s health. They include risk-appropriate perinatal care (NPM3), breastfeeding (NPM 4) and safe sleep (NPM 5).
Risk-Appropriate Perinatal Care. In 2018, Maryland reported that 79.2% of very low birthweight (VLBW) infants were born in a level III or higher NICU, which represents an increase of approximately 1% since 2017. Maryland saw its highest percentage of VLBW infants with level III or higher NICU in 2013 (82.8%) and saw a negative trend until 2018. As of 2018, the percentage of VLBW infants born in a level III or higher NICU did not quite meet the Healthy People 2020 objective of 83.7%.
Breastfeeding. In 2016, Maryland was slightly above the national average for infants ever breastfed (84.1% and 83.8%, respectively). Both nationally and in Maryland, there is an upward trend for infants ever breastfed, apart from 2015, where Maryland saw a spike of 91.0% infants breastfed before falling slightly in 2016. As of 2016, infants ever breastfed in Maryland met the Healthy People 2020 objective of 81.9%.
Safe Sleep. In 2017, Maryland reported an increase in the percentage of infants placed to sleep on their backs (78.2%), which is slightly less than the national average (79.8%). As of 2017, safe sleep in Maryland met the Healthy People 2020 objective of 75.9%.
NPM 3: Risk Appropriate Perinatal Care
The strategy selected for this NPM is to continue standardizing definitions for hospital levels of care. This entails defining hospital levels of neonatal care and levels of maternal care using AAP and ACOG/SMFM guidelines.
In 2019, ACOG/SMFM in collaboration with physicians and a CDC representative developed a revision of the original 2015 Levels of Maternal Care Obstetric Care Consensus. The revision was primarily to clarify terminology and present more recent data and literature. The standardized classification system establishes levels of maternal care, including basic care (level I), specialty care (level II), subspecialty care (level III) and regional perinatal health care centers (level IV)[1].
The Maryland Perinatal System Standards
Maryland has had a systematic approach focused on improving the perinatal care system and reducing infant mortality for over ten years. Indeed, since the mid-1990s, Maryland has had a systematic approach to improving the perinatal system of care and assuring delivery of very low birthweight (VLBW) infants at hospitals with the appropriate level of care. A Perinatal Clinical Advisory Committee within MCHB was formed to develop, review and update the Maryland Perinatal System Standards for all levels of perinatal and neonatal care. This multidisciplinary committee includes representatives from more than 15 Maryland State agencies and professional organizations, as well as from level II to IV delivery hospitals.
The Standards are updated (most recently in 2018) to maintain consistency with AAP and ACOG/SMFM’s Guidelines for Perinatal Care and the AAP Policy Statement on Levels of Neonatal Care. The Standards specify that VLBW births should occur at level III and IV hospitals, which have the necessary subspecialty obstetrical care and neonatal intensive care.
Maryland Maternal Health Innovation Program, MDMOM
MDMOM, the Maryland Health Innovation Program, is a five-year HRSA funded program to improve maternal health across the state. MDMOM is a collaboration between Johns Hopkins University, Maryland Department of Health, Maryland Patient Safety Center and the University of Maryland, Baltimore County who work together to coordinate innovation in the areas of data, resource availability and hospital and community care.
The Maryland Maternal Health Task Force was convened by the MDH to address the needs of pregnant and postpartum women in Maryland. The Task Force is chaired by the Title V Manager and brings a diverse group of key stakeholders together. Task Force members are assigned to workgroups, which are formed around important focus areas in the 5-year Strategic Plan to improve maternal health in Maryland, including: 1) maternal health data, 2) telemedicine, 3) quality improvement, 4) training innovation, and 5) policy. Title V Manager, Colleen Wilburn, MPA, currently serves as the Project Coordinator and Chair for MDH. The purpose of the Task Force is to advise and make recommendations to the Maryland Department of Health on policies to improve maternal health throughout the state.
NPM 4: Breastfeeding
The strategy selected for this NPM is to provide all postpartum mothers with breastfeeding information and providing appropriate referrals to lactation consultant services before discharge. This strategy entails informing pregnant women and new mothers about lactation consultant services and ensuring that lactation consultants have access to new mothers after birth. As part of this strategy, Title V may consider utilizing doulas in a similar role as lactation consults to promote breastfeeding.
This strategy is considered to have moderate evidence, where “dedicated lactation specialists may play a role in providing education and support to pregnant women and new mothers wishing to breastfeed and to continue breastfeeding to improve breastfeeding outcomes” was shown in various systematic literature reviews[2].
Maryland Hospital Breastfeeding Policy
The Maryland Department of Health (MDH) formed an 11-member committee, which includes the Title V Manager, to develop breastfeeding policy recommendations that will strengthen and improve current maternity care practices. The first finalized policy recommendations were completed in September 2012. These policy recommendations, based on WHO/UNICEF Ten Steps to Successful Breastfeeding, include evidence-based hospital practices to increase rates of breastfeeding initiation, duration and exclusivity for healthy, fully term infants whose mothers have chosen to breastfeed. The committee currently meets biannually and provides provider training and hospital policies for Baby-Friendly hospitals.
In 2012, MDH launched a statewide initiative to help hospitals improve the support that hospitals give to breastfeeding mothers. All 32 birthing hospitals committed to this quality improvement process. In 2016, almost 85% of the birthing hospitals reaffirmed their commitments. Hospitals are encouraged to sign a letter of intent to become designated as Baby-Friendly through the Baby-Friendly Hospital initiative, or to follow the Maryland Hospital Breastfeeding Policy Recommendations. As of 2020, 10 hospitals reaffirmed their commitments, representing approximately 31% of birthing hospitals.
Maternity Staff Training
Under the guidance of the Hospital Breastfeeding Policy Committee, and in a collaboration between International Board Certified Lactation Consultants (IBCLCs) at the Maryland Department of Health and the University of Maryland Upper Chesapeake Medical Center, a series of 15 maternity staff training modules were developed. The modules provide education and expertise needed to meet both the Maryland Hospital Breastfeeding Policy Recommendations and the Baby Friendly Hospital Initiative.
Technical Assistance Calls
The Maryland Hospital Breastfeeding Policy Committee offers technical assistance conference calls three to four times a year, on average, to help hospitals with implementation of the Maryland Breastfeeding Policy Recommendations and Baby Friendly Ten Steps. These calls include practical steps and information from IBCLCs, staff nurses, administrators and policy committee members from across Maryland. The experts on the call, professionals from hospitals achieving the topic at hand, lead the conversation about best-practices and ideas on how to best implement the topic being discussed. Past recordings on Auditing and Quality Improvement, Skin-to-Skin and Breastfeeding Training Resource Webinar are still available for listening.
Physician Webinar Series
In 2016, the Maryland Hospital Breastfeeding Policy Committee coordinated a six-lecture series of free webinars about breastfeeding-related topics[3]. These webinars provided continuing medical education (CME) credits, as well training sessions help fulfilled the Baby Friendly USA and the Maryland Hospital Breastfeeding Policy Recommendations. CME credits were available at no cost until June 2019.
Maryland WIC Program
The Maryland WIC Program is committed to helping families have positive, successful breastfeeding experiences. WIC provides resources, such as a FAQ sheet, handouts and a breastfeeding checklist available in both English and Spanish, as well as videos that provide information on various breastfeeding-related topics.
NPM 5: Safe Sleep
The strategy selected for this NPM is to build on safe sleep campaigns by engaging Title V programs and community partners. This strategy entails a professional training made available to Home Visitors, Healthy Start providers and other direct service providers in the community who work directly with expecting and new mothers and families to emphasize a nuanced approach to take family needs, beliefs and context into account when talking about safe sleep.
This strategy is a new approach and is supported by the “Building on Campaigns with Conversations” series of modules developed by the National Center for Education in Maternal and Child Health (NCEMCH). The modules received extensive input from the National Action Partnership to Promote Safe Sleep (NAPPSS) coalition of more than 70 national organizations. Furthermore, this approach is based on Ajzen’s Theory of Planned Behavior and follows current American Academy for Pediatrics (AAP) recommendations for safe sleep.
Morgan State University (MSU) Safe Sleep Project
The Morgan State University (MSU) Safe Sleep Project is funded by MCH with Title V funds. The Project was started in 2019 and aims to provide safe sleep messaging in African-American communities through the development of a social marketing campaign. Focus groups were conducted in two Baltimore City communities to understand why African American communities are not using safe sleep practices. Currently, the Program is working on a video that speaks to myths about safe sleep practices in communities of color. This video will be distributed to local health departments and home visiting programs throughout the state
Surveillance & Quality Improvement Program
The Surveillance & Quality Improvement Program works with mothers who had a fetal or infant loss to gain information about their experience. The Program is funded with Title V funds, where money goes to support both the Fetal and Infant Mortality Review (FIMR).
FIMR
The Maternal and Child Health Bureau, housed within the Maryland Department of Health, serves as the lead agency for Maryland’s FIMR Program. There are 18 FIMR projects in Maryland which represent all 24 jurisdictions, of those 16 are jurisdiction level programs and two are regional FIMR programs.
FIMR teams work to identify various findings, recommendations and action steps for improving systems of care for pregnant women and infants. Recent recommendations include improving access to prenatal care, family planning, bereavement and other mental health services and substance abuse services. Additionally, they recommend increased screening for domestic violence, safe infant sleep practices and improved case management.
Babies Born Healthy (BBH) Grantees
[1] https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2019/08/levels-of-maternal-care
[2] https://www.mchevidence.org/documents/NPM-Webinar-3-04-22-20.pdf
[3] https://phpa.health.maryland.gov/mch/Pages/Hospital_Breastfeeding_Physician_Training.aspx
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