The Health Resources and Services Administration (HRSA) has identified three National Performance Measures (NPM) for perinatal/infant health: 1) ensuring that higher risk mothers and newborns delivery at hospitals that are able to provide appropriate care (NPM 3); 2) increasing the number of infants who are breastfed and those who are exclusively breastfed through 6 months (NPM 4); and 3) increasing the number of infants placed to sleep on their backs (NPM 5).
To this end, the state of Maryland, as a result of the 2021-2025 Needs Assessment, has identified all three perinatal/infant health performance measures as priorities over the next five years. As part of the objective to improve perinatal/infant health, Maryland will also look to reduce the racial disparities within these performance measures.
Objective 1: Increase the number of very low birth weight babies from 93.4% (Baseline, 2019) to greater than 95% by 2025 will be born in hospitals with the appropriate level of care.
NPM 3: Risk Appropriate Perinatal Care
The strategy selected for this NPM is to continue with the oversight and compliance review of the standardized definitions for birthing hospital levels of care. Maryland has had a systematic approach focused on improving the perinatal care system and reducing infant mortality for over ten years. 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.
The Maryland Perinatal Standards of Care defines hospital levels of neonatal care and levels of maternal care using American Academy of Pediatrics (AAP) and American College of Obstetrics and Gynecology (ACOG)/ Society of Maternal Fetal Medicine (SMFM) guidelines. The standardized classification system includes: basic care (level I), specialty care (level II), subspecialty care (level III) and regional perinatal health care centers (level IV)[1].
The Maryland’s Perinatal Clinical Advisory Committee reconvened in 2018 to revise the Standards in order to be consistent with the 8th edition of the Guidelines for Perinatal Care, issued in 2017 jointly by AAP and ACOG.
Standards are incorporated into the regulations for designation of perinatal referral centers (Level III and Level IV hospitals) by the Maryland Institute for Emergency Medical Services Systems (MIEMSS) , as well as the Maryland Health Care Commission’s State Plan regulations for obstetrical units and neonatal intensive care units.
For FY 2024, the MIEMSS Perinatal Advisory Committee will meet quarterly. All Level III and IV Perinatal Referral Center re-designations are up to date, so no further site reviews will occur during FY 2024.
For FY2024, the Morbidity, Mortality, and Quality Review Committee (MMQRC) will continue to monitor voluntary compliance of Level I and Level II hospitals with the Standards with six site reviews. The MMQRC will continue to meet quarterly.
Maryland Perinatal Support Program
The purpose of the Maryland Perinatal Support Program (MPSP) is to support and improve the perinatal system of care in Maryland. While Level III and Level IV perinatal hospitals (as defined in the Maryland Perinatal System Standards and designated by MIEMSS) are required to have maternal-fetal medicine physicians on staff, the Level I and II hospitals, community health clinics, and obstetric care providers often do not have access to such specialists. Maternal-fetal medicine specialists can provide unique support in the evaluation and management of pregnant and postpartum patients with pre-existing medical conditions, pregnancy complications, or known/suspected fetal anomalies. Support provided by a maternal-fetal medicine specialist through consultation, education, and technical assistance to obstetric providers may allow a woman to continue care within her community. Such support may also assist an obstetric provider in determining whether a pregnant patient would need to transfer her prenatal care to a specialty center. MPSP brings maternal-fetal medicine consultation, education and technical assistance, as well as obstetric nursing outreach and education, to providers in all regions of the State. Consultation and other technical assistance are provided virtually via secure internet hosts, through scheduled webinars and online meetings, and also onsite (e.g. at the hospitals, clinics, or offices), as needed. These services are provided without charge to the hospital or obstetric provider.
The three goals of the Maryland Perinatal Support Program are 1.) to assist in providing risk appropriate perinatal care, 2.) to assist providers with determining if a prenatal patient will need to transfer her care to a specialty center, and 3.) provide evidence based guidelines for obstetrical care.
During FY2024, Title V will further understand the needs from Level I and II hospitals, Federally Qualified Health Centers (FQHCs), and obstetric care provider practices across the state through key informant interviews and focus groups.
Maryland Perinatal- Neonatal Quality Collaborative
Fiscal Year 2023 will mark the two-year maternal (hypertension) and neonatal (antibiotic stewardship) initiatives selected by the MDPQC Steering Committee. Steering Committee members consist of providers, public health officials, payors, patient representatives, and representatives of professional societies. 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 will be organized 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.
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. While the Task Force was previously chaired by the Title V Manager, in order to have a committee led by partners, an election was held to vote for co-chairs. Two co-chairs were elected from a community based organization and another from an academic university. The Task Force developed a statewide strategic plan with five areas of focus: 1) Equity and antiracism, 2) Achieve health using the life course model, 3) Families and Communities, 4) Data, and 5) Workforce. During the next Fiscal Year, Title V will partner with MDMOM and the Task Force to create a resource inventory of maternal health providers and services in Maryland. In addition, TItle V will work with the the co-chairs to continue refining the strategic plan and implementing the outlined activities n through coordination through multiple partners.
Surveillance Quality Initiatives
In FY2024, Surveillance Quality Initiatives (SQI) such as Child Fatality Review (CFR) and Fetal and Infant Mortality Review (FIMR) will continue to identify systemic preventive factors to improve perinatal health in Maryland. The goal of the SQI funding to local jurisdictions is to develop, implement, and align recommendations aimed at improving rates of infant and child fatalities. For Fiscal Year 2024 (FY 2024), jurisdictions will continue to address the following priorities as part of their funding:
- Dissemination of information and education on sleep-related infant death and Safe Sleep to reduce sleep-related infant death
- Develop recommendations addressing racial disparities in infant, fetal, and child deaths
- Practices, particularly among communities at highest risk of sleep-related infant death;
- Conduct screening, provide referrals to reduce incidence of substance use disorder and transmission of sexually transmitted infections (STIs) in pregnancy
- Increasing social supports for women during the perinatal and postpartum periods
In addition, jurisdictions will now include a health equity strategy into their program efforts using one of the following priority areas:
- Workforce development
- Analyzing program data by racial/ethnic group to inform program design and to measure progress
- Pursue program or community policy change
- Making data available to your target community
- Engaging community in program development and evaluation
The Maternal and Child Health Bureau, housed within the Maryland Department of Health, serves as the lead agency for Maryland’s Fetal Infant Mortality Review (FIMR) Program. Funded by Title V, our FIMR program works with program staff in jurisdictions with the highest rates of fetal and infant mortality. Infant and child mortality are two of the most critical indicators of the overall health of a population, and Maryland has made significant strides to improve infant and child health. In 2021, the infant mortality rate in Maryland was 6.1/1,000, representing a 7% increase from the 2020 rate, and a 21% overall decrease from the average of 7.8/1,000 from 2012-2016. Significant racial/ethnic disparities persist and work remains to be done: there was a1% decrease in the non-Hispanic Black infant mortality rate, from 2020 to 2021. Additionally, the non-Hispanic Black infant mortality rate (9.8/1,000) is 2.6 times higher than that of the non-Hispanic White infants (3.7/1,000). There was also an increase in the rate of infant mortality for Hispanic infants, from 4.6/1,000 to 5.3/1,000.
There are currently 7 funded FIMR projects in Maryland, operating in the jurisdictions identified via PPOR analysis as having the highest rates of infant mortality in the state. They include Anne Arundel, Charles, Prince George’s, Montgomery, Wicomico, and Baltimore Counties and Baltimore City. The Fetal Infant Mortality Review was designed to be a community-owned action-oriented process to improve service systems, and works to examine the medical, non-medical and systems related factors contributing to fetal and infant death at the community level. Each local team works with their Community Action Teams (CAT) to develop program and policy recommendations to improve maternal and fetal outcomes. Leveraging the recommendations of the CAT teams, health departments will now be required to implement interventions aimed at addressing factors contributing to preventable maternal and infant deaths in Maryland.
In FY 2024, FIMR CAT teams will be asked to identify gaps and expand interventions to reduce infant mortality, with specific focus on substance use disorder, reducing disparities, and reducing sleep-related infant deaths.
In FY 2024, FIMR teams will select cases for review based on the categories of fetal and infant death where the largest disparities are present within their jurisdictions. Teams are also expected to conduct case reviews with one or more of the following risk factors present: substance use during pregnancy; birth defects or fetal anomalies; significant maternal health conditions (hypertension, gestational diabetes); maternal history of fetal loss; or SARS-CoV-2 infection during pregnancy. Teams will also look at how a lack of transportation, housing instability, food insecurity contributed to fetal or infant death. In addition, sites will have the opportunity to pilot using the National Center for Fatality Review & Prevention (NCFRP) database to log reviewed case information. Teams will work to identify various findings, recommendations and action steps for improving systems of care for pregnant people and infants. Recent recommendations include developing educational materials for providers and patients on the importance of early prenatal care and “counting kicks”, improving access to family planning, bereavement and other mental health services and substance use disorder services. A significant part of the review is incorporating the voices of postpartum people who experience a fetal loss in addition to reviewing the medical aspects of the case, with Maternal Interviews being central to the FIMR process. In FY 2024, FIMR teams will focus on Maternal Interviews as a strategy area for quality improvement. FIMR teams will address health equity in their review process and FIMR CAT program to improve health disparities in their local jurisdiction.
Objective 2: Increase the number of infants who are breastfed from a baseline of 88.6% to 90% (National Immunization Survey).
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/birth workers in a similar role as lactation consultant 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. During FY24, these state trainings will be updated. They were planned to be updated in FY23, but were unable to do so due to the network security event and the inability to view these modules on the shared drive.
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 and will continue to be available inFY24.
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 fulfill the Baby Friendly USA and the Maryland Hospital Breastfeeding Policy Recommendations. CME credits were available at no cost until June 2019. These sessions continue to be online. In Fiscal Year 23, these series will be updated. They were not updated in FY22 due to the network security event.
Maryland WIC Program
The Maryland WIC Program continues to be committed to helping families have positive, successful breastfeeding experiences. WIC will continue to provide 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. Maryland WIC employs 31 breastfeeding peer counselors who will continue to provide ongoing one on one support to pregnant and breastfeeding participants.
Objective 3: Increase the number of babies who are placed on their back to sleep as reported by PRAMS from 78.5% to the Healthy People 2030 target of 88.9%
NPM 5: Safe Sleep
The Maryland Department of Health will conduct a literature scan, review strategies from other states, and review existing data about infant safe sleep. We will procure a vendor to lead a Statewide infant safe sleep conference in FY2023. This conference will focus on integrating evidence-informed infant safe sleep strategies into practical messaging for a variety of stakeholders. The conference will gather community members with lived experience, community based organizations, local health departments, and other entities to share The strategy selected for this NPM is to build on infant 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.
Local Health Departments
Local Health Departments through Babies Born Healthy (BBH) and Care Coordination Units will continue to provide information related to Infant Safe Sleep. In addition, sites with portable crib programs will continue to provide portable cribs for families in need.
Babies Born Healthy (BBH)
During FY24, the new iteration of Babies Born Healthy will be implemented. To develop the new iteration, the Title V team underwent a strategic refresh assessment. This strategic program refresh was informed by a process of assessing the most up-to-date data and evidence and aligning with other major infant mortality initiatives such as the Statewide Integrated Health Improvement Strategy. The refresh process consisted of further examining the following outcome measures to determine jurisdictional priorities: infant mortality rate and numbers by jurisdiction, disaggregated by race and ethnicity, low birth weight, preterm birth weight, access to prenatal care, and other indicators such as social determinants of health indicators and maternal health indicators. Existing programmatic data such as quarterly reports, surveys, and key informant interviews and a scan of evidence-based practices that improve infant health were also reviewed. The renewed focus will be on decreasing disparities, strengthened outcome measures, and building evaluation into the program.
The goal of Babies Born Healthy (BBH) is to identify and link at-risk pregnant people to essential services that have been associated with improved birth outcomes, to decrease disparities in infant mortality, specifically between non-Hispanic Black and non-Hispanic white populations.
In FY 2024, Babies Born Healthy will support the following program areas:
- Continue Perinatal Care Coordination: BBH will continue to fund Perinatal Care Coordination in eight (8) jurisdictions and specifically with Local Health Departments (LHDs). BBH sites will continue to conduct targeted outreach to engage pregnant people in high-risk neighborhoods in their jurisdiction, and to those who are determined high-risk due to medical or social needs. LHDs will connect clients to medical and social services programs, including establishing a medical home and access to prenatal care. Prenatal care is crucial in preventing pregnancy complications and managing pre-existing and pregnancy-related conditions that could have an adverse effect on both the pregnant person and their infant.[4] Receiving no, or late, prenatal care can result in a number of adverse health outcomes for both the pregnant person and infant, including preterm birth, low birth weight, increased risk of perinatal mood and anxiety disorders (PMADs), severe maternal morbidity, and maternal mortality.[5]Program redesign elements will strengthen care coordination metrics, technical assistance and resources for sites to standardize the sites. Sites will engage with clients who are experiencing PMADs and/or substance use disorder, for a minimum of 6-months postpartum.
- Initiate a Maryland Doula Training Hub: As part of SIHIS, Maryland Medicaid will reimburse for home visiting and doula provider services. In order to align with Medicaid and SIHIS goals, BBH will support the development of a Doula Training Hub. The Doula Hub will increase the number of doula providers enrolled in Medicaid. Specifically, the Doula hub will facilitate the recruitment, training, and reimbursement of community-based, perinatal doulas, to serve clients in their community during the perinatal period. The hub will provide technical assistance to participating doulas to become eligible for Medicaid reimbursement for their services. Title V staff has worked closely with Maryland Medicaid to ensure that the Hub is complementary to the new Medicaid benefit that provides Medicaid reimbursement for doula services. Community-based doula programs have been recognized by AMCHP as a best practice, and HRSA is currently funding Community based doula programs under the HealthyStart program as part of their efforts to improve health outcomes before, during, and after pregnancy, and reduce racial/ethnic differences in rates of infant death and adverse perinatal outcomes.[6],[7] Improving access to doula services to high-risk pregnant people can address persistent disparities in health outcomes, while addressing a variety of access needs within a continuum of care framework.
- Increase the number of CenteringPregnancy sites in Maryland: group prenatal care has been identified as a promising intervention with the best potential to improve maternal and infant health outcomes, and decrease disparities. In Maryland, infants of Black birthing people experience increased rates of infant mortality and preterm birth compared to infants of White birthing people. Additionally, Black birthing people have been found to have nearly twice the rate of severe maternal morbidity (SMM) as compared to White birthing people.The CenteringPregnancy model of group prenatal care is an evidence-based health care delivery model that integrates maternal health care assessment, education, and support. With over 100 published studies and peer-reviewed articles, evidence shows that CenteringPregnancy reduces costs, lowers the risk of preterm birth, closes the disparity gap in preterm birth between Black and White women[8].
- Build in Evaluation for the BBH Initiative: Additionally, funds will be allocated to support the evaluation of the Babies Born Healthy Program to establish program impact and to inform program evolution in the future
In FY 2024, there will continue to be strong guidelines on how LHD BBH care coordination programs should plan and execute their care coordination services, including guidance on screening, care planning, and engagement. Babies Born Healthy has also been brought into closer alignment with FIMR/CFR programming in order to synergize reports and incidents of deaths and the jurisdictional response to address the causes of death.
[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
[4] What is prenatal care and why is it important? https://www.nichd.nih.gov/. Accessed February 7, 2022. https://www.nichd.nih.gov/health/topics/pregnancy/conditioninfo/prenatal-care
[5] https://www.cms.gov/About-CMS/Agency-Information/OMH/equity-initiatives/rural-health/09032019-Maternal-Health-Care-in-Rural-Communities.pdf
[7] Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2017, Issue 7. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub6.
[8] https://www.centeringhealthcare.org/why-centering/research-and-resources
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