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

Perinatal Health Application Year

The Health Resources and Services Administration has identified three national performance measures for perinatal/infant health:

1. Ensuring that higher risk mothers and newborns deliver 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).
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.

In FY25, Title V staff will continue to partner with other programs throughout the department to align perinatal health efforts, particularly for the rise in congenital syphilis and perinatal HIV transmissions. During the 2024 Maryland legislative session, the Maryland Giving Infants a Future without Transmission (GIFT Act/House Bill 119) bill was passed, which expands testing requirements for syphilis and improves HIV surveillance for pregnant people. Title V staff supported the development and passage of the bill with the Infectious Disease Prevention and Health Services Bureau. Title V staff also partnered with IDPHSB to launch a campaign on pregnancy care and HIV, syphilis and hepatitis prevention in 2024. This media campaign includes an updated web page with resources for pregnancy care and testing; digital, bus and metro ads; billboards and screen ads at pharmacies and points of care.

In FY25, Title V staff will continue to work closely with IDPHSB to align initiatives that reduce congenital syphilis and perinatal HIV transmission further. Staff will continue to disseminate the campaign on pregnancy care and HIV, syphilis and hepatitis prevention amongst the maternal child health workforce - particularly community health workers, public health and home visiting nurses, and clinical providers. Title V staff will also partner with 211 to update perinatal resources for birthing people and providers in Maryland. Title V staff will plan to partner with IDPHSB to implement the GIFT Act, specifically by coordinating with all 32 birthing hospitals for these new testing requirements.

In preparation for the respiratory syncytial virus (RSV) season for 2024-2025, Title V staff will partner with the Infectious Disease Epidemiology, Outbreak, and Response Bureau to prepare and plan to decrease hospitalizations due to RSV.  RSV is a common respiratory viral illness that causes mild, cold-like symptoms in healthy adults but that can cause serious illness in infants and older adults. Between 2021 and 2023, the virus caused 603 - 1129 hospitalizations per year for children less than 2 years old in Maryland.[1] The typical RSV season begins in October and lasts through April. In 2023, two highly effective methods of prevention became available:

• Abrysvo is a vaccine that the CDC recommends be administered to birthing people who are 32 - 36 weeks pregnant during September through January.
• Beyfortus (Nirsivimab) is a monoclonal antibody that the CDC and AAP recommend be administered to infants under 8 months old born during, or entering, their first RSV season. Some children between the ages of 8 and 19 months who are at increased risk of severe RSV disease qualify to receive Beyfortus before their second RSV season.

Beyfortus is not necessary for infants born to a birthing person who received Abrysvo during the recommended window unless they are born <14 days after vaccination.

Objective 1: Increase the number of very low birth weight babies from 93.4 percent (baseline, measured in 2019) to greater than 95 percent by 2025 will be born in hospitals with the appropriate level of care.

During 2025, Title V staff will partner with other Department staff, pediatric, prenatal, and birthing people partners to ensure that birthing people have easy access to Abrysvio and birthing hospitals as well as pediatric providers administer Beyfortus to newborns and infants. This includes sharing guidance developed from the Centers for Disease Control and Prevention and other professional societies and partnering with the Vaccines for Children program. The goal is to enroll as many birthing hospitals in the Vaccines for Children program so they may have Nirsivimab available. Furthermore, Title V staff will partner with IDEORB to outreach pharmacies who also may administer Abrysvo.

 

Risk Appropriate Perinatal Care (NPM 3)

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 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 and American College of Obstetrics and Gynecology/Society of Maternal Fetal Medicine 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)[2].

In 2024, an ad hoc Perinatal Clinical Advisory Committee was convened with 28 volunteer members representing five State agencies, eight professional organizations and the four levels of perinatal hospitals in Maryland. The Committee members updated the standards. There were no major changes as there were no changes to national professional guidance. 

In fiscal year 2025, the revised perinatal system standards will be finalized and disseminated with partners. The revised standards will be 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, as well as the Maryland Health Care Commission’s state plan regulations for obstetrical units and neonatal intensive care units. The Morbidity, Mortality, and Quality Review Committee will also use the revised standards for their site visits of Level I and II birthing hospitals. A one-year transition period will also be permitted so that hospitals have time to implement changes.

 

Maryland Perinatal-Neonatal Quality Collaborative

In FY25, the Perinatal-Neonatal Quality Collaborative will continue to partner with the Bloom Collective to deliver training and technical assistance to healthcare providers to center Black birthing people in quality improvement efforts. As the PQC recently started the Parent and Baby Advisory Council. This council is a group of patients, family members, caregivers and community members collaborating to support practices that enhance the quality and delivery of safe care for all birthing persons, babies and children.

The Maryland PQC will focus its second year on implementing the severe hemorrhage safety bundle as well the neonatal hypoglycemia bundles. Furthermore, the PQC will focus on sustained implementation of the severe maternal hypertension bundles, particularly in the emergency department setting to make sure they screen patients for a history of pregnancy. The in-person learning event will be organized in the Fall of 2024 to provide updates and invite high performers to share best practices and lessons learned. The Maryland PQC will continue to heavily focus on health disparities, and will push out data-driven improvement activities and resources to promote health equity.

In FY25, Title V staff, specifically the bureau director will participate in the Health and Human Services Postpartum Collaborative. Maryland is one of six states to participate. 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. The aim is to decrease postpartum hospital readmissions among populations at participating care centers across New Mexico, Minnesota, Massachusetts, Michigan, Iowa and Maryland by January 31, 2025. According to Maryland Medicaid data from calendar year 2022, nearly one in five readmissions in the first 42 days were due to complications from hypertensive disorders of pregnancy. Therefore as part of the collaborative, Title V staff will partner with one to three birthing hospitals to ensure avoidable hospital readmissions due to hypertensive disorders of pregnancy are reduced. Title V staff will work with Health Quality Innovators, the PQC vendor, to implement a remote blood pressure monitoring program, ensure postpartum appointments are made, and to refer patients to local health departments for community-based resources.

 

Maryland Maternal Health Innovation Program

The Maryland Health Innovation Program, as referred to as MDMOM, 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 to coordinate innovation in the areas of data, resource availability, and hospital and community care.

The Maryland Maternal Health Improvement Task Force addresses the needs of pregnant and postpartum women in Maryland as well as provides input to the MDMOM initiatives. The co-chairs, Dr. Donna Neale and Tanay Lynn Harris, were elected previously from committee members. In 2021, 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.
5. Workforce.

 

In FY25, Title V will partner with task force members and the Maternal Health Learning and Innovation Center to update the strategic plan. Furthermore, Title V staff supported task force members and MDMOMs to create a resource inventory of maternal health providers and services in Maryland. Title V will partner with task force members and 211 to sustain updating the resource inventory.

 

Surveillance Quality Initiatives

In FY 2025, Surveillance Quality Initiatives including the Child Fatality Review and the Fetal and Infant Mortality Review will continue to identify systemic preventive factors to improve perinatal health in Maryland. SQI initiatives are funded through general state funds, which are used as the Title V state match. 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 FY25, jurisdictions will focus on implementing Senate Bill 59 (Hospitals: Care of Infants after Discharge) that requires all birthing hospitals to provide education on safe sleep education and resources. The program will also prioritize increasing maternal and child health communications, particularly to communicate the recommendations from child fatality reviews with partners.

For FY25, 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 and provide referrals to reduce incidence of substance use disorder and transmission of sexually transmitted infections in pregnancy.
• Increasing social supports for women during the perinatal and postpartum periods.

 

In addition, jurisdictions will 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.

 

Fetal Infant Mortality Review

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 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.

There are currently seven funded FIMR projects in Maryland operating in the jurisdictions identified through a perinatal periods of risk 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. It 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 to develop program and policy recommendations to improve maternal and fetal outcomes. Leveraging the recommendations of the community action teams, health departments will now be required to implement interventions aimed at addressing factors contributing to preventable maternal and infant deaths in Maryland.

In FY25, a strategic review of FIMR resource allocation will be conducted to ensure that the program is supported in jurisdictions with the highest number of fetal and infant mortality. This is usually conducted every five years.

In FY25, 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 expected to conduct case reviews with one or more of the following risk factors present: substance use during pregnancy, birth defects or fetal anomalies. Teams will also look at how a lack of transportation, housing instability and food insecurity contributed to fetal or infant death. In addition, sites will have the opportunity to continue to pilot using the National Center for Fatality Review and Prevention 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 FY25, FIMR teams will continue to focus on maternal interviews as a strategy area for quality improvement. FIMR teams will address health equity in their review process and the FIMR community action team program to improve health disparities in their local jurisdiction.

In FY25, the SQI program will explore regionalization of FIMR reviews in western Maryland. The program would like to prioritize western Maryland to better understand their emerging trends as several perinatal providers will travel from West Virginia to care for Maryland residents. Given the relatively fewer fetal and infant cases, partnering together would allow for efficient use of resources.

 

Breastfeeding (NPM 4)

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. 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.[3]

Objective 2: Increase the number of infants who are breastfed from a baseline of 88.6 percent to 90 percent (measured by the National Immunization Survey).

As part of this strategy, Maryland’s Title V program will use home visitors, perinatal care coordinators and doulas/birth workers in a similar role as lactation consultants to promote breastfeeding. Maryland Title V staff will disseminate existing training opportunities. Virtual pre-recorded training about milk supply, mothers and infants with specific needs, supporting mothers who feed with bottles, and breast and nipple concerns are available (Training website). Furthermore, Maryland Title V staff will partner with 211 to ensure specific lactation supports are available.

In FY25, the Title V manager, once onboarded, and the perinatal health manager will join the WIC staff in participating in the Breastfeeding Coalition. Furthermore, Title V will partner with workplaces, childcare providers and healthcare providers to confer Breastfeeding-Friendly Awards. Maryland’s Title V will explore the barriers for hospitals receiving the baby-friendly designation.

Maryland Title V staff will also disseminate tools about breastfeeding.

 

Technical Assistance Calls

The Maryland Hospital Breastfeeding Policy Committee as part of the Maryland Breastfeeding Coalition 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 who are experts in 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 webinars are still available for listening and will continue to be available in FY25.

 

Maryland Women Infants and Children 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). They will also provide videos with 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. WIC staff will continue participating in the Maryland Breastfeeding Coalition.

 

 

 

Safe Sleep (NPM 5)

Objective 3: Increase the number of babies who are placed on their back to sleep (as reported by PRAMS) from 78.5 percent to the Healthy People 2030 target of 88.9 percent.

Maryland’s Title V will continue to review existing data about infant safe sleep to improve the state’s infant safe sleep strategy. During the 2024 Maryland legislative session, HB 177/SB 59 - Hospitals - Care of Infants After Discharge (Safe Sleep Act of 2024) passed, requiring hospitals to provide information and resources related to providing a safe sleep environment, and MDH to provide a resource list of safe sleep resources by jurisdiction. Title V plans to partner with an organization to provide technical assistance to birthing hospitals and aid in the development of the resource guide to support in the implementation of this legislation. The organization will be selected through the department’s procurement process. The organization will also plan and implement a statewide infant safe sleep summit in FY25. 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 national performance measure. This work is to build on infant safe sleep campaigns by engaging Maryland 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). The modules received extensive input from the National Action Partnership to Promote Safe Sleep, a 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 recommendations for safe sleep.

 

Local Health Departments

In FY25, it is expected that eight local health departments will use Title V funds to provide perinatal care coordination or perinatal home visiting services. The local health departments include Baltimore City, Baltimore County, Calvert County, Caroline County, Cecil County, Harford County, Kent County, and Montgomery County. A total of $1,901, 510 will be used for these services. Half of these funds are counted towards maternal health and half are counted towards infant health. Of note, it is expected that Garrett County will use Title V funds for home birth certification.

Local health departments will continue to provide information related to infant safe sleep as well as provide portable cribs for families in need. 

 

Improving Perinatal Health through Perinatal Care Coordination

Perinatal care coordination programs provide support to pregnant people, their infants, and their families to coordinate services for a healthy pregnancy. Community Health workers and public health nurses refer to long-term maternal, infant, early childhood home visiting and WIC; screen for substance use/misuse and refer to treatment; provide safe sleep education, family planning education and much more. Perinatal care coordination sites are funded by Medicaid through grants for the Administrative Care Coordination Units and public health programs through Title V,  Babies Born Healthy and Thrive by Three funds. BBH and Thrive by Three funds are used as Title V state matches.

 

Babies Born Healthy- Perinatal Care Coordination

The goal of the Babies Born Healthy Program is to improve birth outcomes, specifically to decrease disparities in infant mortality, especially between non-Hispanic Black and non-Hispanic white populations. In FY25, Babies Born Healthy will continue in eight jurisdictions, specifically with local health departments. Title V staff will also implement HRSA’s Integrated Maternal Health Services Program which will increase referrals to the local health departments for increased services that address social needs. In FY25,  Title V staff will work with BBH site, Prince George’s County, as the pilot location to digitize the Maryland Prenatal Risk Assessment and the Postpartum Infant Maternal Referral Form.

All  BBH sites will continue to conduct targeted outreach to engage pregnant people in high-risk neighborhoods in their jurisdiction and those who are determined high-risk due to medical or social needs. Local health departments 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, severe maternal morbidity and maternal mortality.[5] The program re-designed elements will strengthen care coordination metrics, technical assistance and resources for sites to standardize the sites. Sites will engage with clients who are experiencing perinatal mood and anxiety disorders and/or substance use disorder, for a minimum of 6-months postpartum.

In FY25, there will continue to be strong guidelines on how 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 prevent future fatalities and address the causes of death.

 

Program Evaluation of BBH

During FY 2025, evaluation of the Babies Born Healthy Program will continue.  Since 2024, Title V has been working with Cardea Services, a national women of color-led organization, to conduct the evaluation. The evaluation will help the department understand to what extent did the BBH perinatal care coordination services reach the intended priority populations and that there is equity in servicing. The evaluation will also understand to what extent support was provided to community-based doulas to enroll in Maryland Medicaid.  

 

Increasing CenteringPregnancy in Maryland

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. 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 and closes the disparity gap in preterm birth between Black and white women[6]. In FY25, CenteringPregnancy sites will expand through the partnership with CenteringHealthCare Institute. State general funds through Babies Born Healthy and SIHIS funds will be braided to expand CenteringPregnancy sites by three sites in 2025.

 

Increasing Doula Support to Improve Perinatal Health Outcomes

Maryland Medicaid reimburses for Nurse Family Partnership and Healthy Families America maternal, infant and early childhood home visiting and doula provider services. Babies Born Healthy will work to increase the number of doulas who will be reimbursed by Maryland Medicaid. In 2024, Maryland Medicaid removed the requirement that community-based doulas must contract with Managed Care organizations and instead be able to use the self-referral billing mechanism. This is anticipated to reduce the barriers for doulas to bill in Maryland. Community-based doula programs have been recognized by the Association of Maternal & Child Health Programs as a best practice. 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.[7],[8] 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.

 

Thrive by Three

Separate from the Babies Born Healthy general funds, the Maryland Prenatal and Infant Care Grant Program Fund or the  “Thrive by Three Funds” help to increase access to prenatal care. These state general funds previously were used to pay for prenatal care to pregnant people who would not qualify for Medicaid due to their citizenship access. However, since July 1, 2023, the Healthy Babies Equity Act (HB 1080) has expanded coverage to pregnant people who are undocumented. More than 11,700 participants have enrolled with the Healthy Babies Equity Act. Therefore, the Thrive by Three funds have shifted to provide perinatal care coordination and behavioral health services. Some of the funds are used to assist in transportation services for people to access their prenatal visits.

In FY25, an additional $1 million in general funds will be allocated to perinatal care coordination and prenatal care access via the Thrive by Three grant program for a total of $3.5 million dollars. Thrive by Three works with four local health departments (Baltimore City, Harford County, St. Mary’s County and Wicomico County) and three Federally Qualified Health Centers (CCI services, Greater Baden Medical Center and Mary’s Center). In FY25, sites will be required to address perinatal mental health through their Thrive by Three program.

[1] Maryland Department of Health. Internal Data - Emerging Infections Program.

[2] https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2019/08/levels-of-maternal-care

[3] https://www.mchevidence.org/documents/NPM-Webinar-3-04-22-20.pdf

[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

[6] https://www.centeringhealthcare.org/why-centering/research-and-resources

[7] The HealthConnect One CommunityBased Doula Program

[8] 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.