MCH Population Needs

MDPH conducts a comprehensive statewide needs assessment every five years and in interim years engages in activities to ensure that needs assessment is an ongoing process. Below are examples of efforts to monitor and assess the continuing needs of the MCH population in Massachusetts.

COVID-19 Community Impact Survey

Under the leadership of BCHAP staff, MDPH and stakeholders conducted the COVID-19 Community Impact Survey (CCIS) to better understand the immediate and long-term health needs of Commonwealth residents during the pandemic, including social and economic consequences. MDPH is using and sharing these data to create new, collaborative solutions with community partners.

The survey was conducted from September – November 2020 and there were over 33,000 adult respondents and over 3,000 youth (under 25) respondents. Findings reinforced that the COVID-19 pandemic is both exacerbating pre-existing public health concerns and creating new health crises to address. Even people who have not become sick with COVID-19 are managing stress, uncertainty, and isolation during this challenging time. Key findings relate to access to healthcare; access to testing; ability to mitigate individual risk of infection; impact on social determinants of health; mental health; employment; parents/guardians; and substance use. Results are being examined by race, ethnicity, sexual orientation, gender identity, transgender status, types of disability, income, education, language spoken, industry/occupation, geography, employment status, age, etc.

Additional information about the CCIS process and findings can be found in the Overview of the State and the State Action Plan Narrative by Domain.

MA Maternal, Infant, and Early Childhood Home Visiting (MA MIECHV)

MDPH contracted with Tufts Interdisciplinary Evaluation Research (TIER) to conduct the MA MIECHV 2020 Needs Assessment. MDPH’s goals were to generate a comprehensive understanding of the needs of families with young children, determine whether existing family support programs are sufficient to both meet families’ needs and effect change at a structural level, and to identify strategies to strengthen the state’s early childhood systems of care.

TIER’s mixed methods approach included synthesizing findings from other needs assessments conducted in Massachusetts; analysis of extant indicators to identify communities experiencing the greatest public health challenges; survey of home visiting programs across funding sources in Massachusetts; focus groups with families, providers, and other key stakeholders (some of this qualitative data collection was done as part of the Title V needs assessment); mapping of available treatment services for families experiencing substance use disorder (SUD)-related challenges; review of MA MIECHV site visit reports to describe SUD-related challenges from the perspective of home visiting programs; and case studies of two innovative home visiting approaches for parents in SUD recovery.

Key findings of importance to Title V include:

• Overall, the cities/towns facing the greatest challenges in Massachusetts were the same as in past MA MIECHV needs assessments. This is not surprising, given the structural inequities that have historically characterized these communities.
• Affordable housing, mental health, and involvement with child protective services consistently emerged as among the most pressing concerns for families.
• Families noted a lack of knowledge about and access to services like home visiting and expressed how challenging it is to navigate the complicated service systems in the state.
• Families experiencing substance-use disorder (SUD) continue to face challenges that are impacted by systemic limitations in the state. Home visiting programs are a primary support to families experiencing with SUD and can serve as critical liaisons with SUD-related services.  Home visiting programs play an essential role in the implementation of the Title V substance use priority.
• There are racial inequities on almost every indicator, including poverty, education, employment, maternal morbidity, maternal mortality, homelessness, and infant death. Researchers, state agencies, home visiting programs, and home visiting staff have a role to play in addressing racism as a root cause of these inequities.

WIC Nutrition Program

An annual needs assessment identifies WIC-eligible populations in all 351 cities and towns. In 2017, WIC revised how it estimates eligibility using indication of Medicaid insurance on the birth certificate (which gives adjunctive eligibility for WIC) for prenatal care or labor/delivery, or WIC prenatal use as proxy of eligibility for WIC. These changes give a more accurate assessment of eligibility but preclude comparison with data from earlier years.

Using the new methodology, 203,077 women, infants, and children were eligible in 2019, compared to 207,249 in 2018, reflecting the decrease in the state’s number of births. Among those eligible in 2019, 47.9% of women, 79.6% of infants, and 48.9% of children participated in WIC. Local WIC agencies use needs assessment results for outreach plans to engage and enroll eligible families.

WIC also conducts an annual participant satisfaction survey. In January 2020, 9,841 surveys were completed, 30% in a language other than English. Overall, 66% of respondents were highly satisfied with WIC, with the highest percentages among non-English speakers. Among women who spoke Spanish and Portuguese, 81% and 77% respectively were highly satisfied, compared to 60% of English speakers. A majority (72%) of participants joined when pregnant, and most new participants learned about WIC from friends and family. Areas for improvement included acknowledging participants’ knowledge and experience as parents when providing nutrition education, clarifying available/allowed foods, and better customer service at WIC offices. 

During the summer of 2020, WIC conducted a survey to assess participants’ needs and satisfaction with using WIC telehealth services which were established due to the COVID-19 pandemic. WIC participants can hold their appointments by telephone or video call and are able to access online education modules in multiple languages through the WICSmart app. Overall, 85% of WIC participants reported that the changes made to WIC made it easy or very easy to access WIC services during the pandemic.

Sexual and Reproductive Health Services

In the FY20 budget, the state legislature directed MDPH to “develop and implement a public information campaign to promote awareness of reproductive health care facilities in the commonwealth, including those that offer or perform abortions…[and]…educat[e] reproductive health care professionals, patients and the general public regarding any and all limitations placed on the use of federal Title X family planning program funds by the U.S. Department of Health and Human Services.” MDPH’s external marketing vendor conducted key informant interviews and an online survey of female and non-binary individuals aged 18-29 with incomes less than $50,000 per year. This information gathering resulted in a successful public information campaign called All of You that promoted the awareness of sexual and reproductive health care services that offered all pregnancy options information and referrals.  

Emerging Issues

MDPH has identified the following emerging public health issues and Title V capacity and resources to address them.

Recovery from COVID-19

COVID-19 continues to change both the lives of families and children and the public health system in innumerable ways. As Massachusetts moves from a state of emergency to reopening and recovery from the pandemic, new concerns and issues arise for the Title V program and MCH population. A primary concern is the potential expiration of enhanced public benefits, such as unemployment, and how this cliff will impact families’ economic stability. There is also uncertainty about the future and sustainability of virtual service delivery models, which have demonstrated both successes and challenges in meeting families’ needs during the pandemic. Efforts are underway to transition back to in-person services, and MDPH will explore the impact and feasibility of continuing virtual services in some capacity. The pandemic has also tested the limits of programs serving the MCH population, such as respite care. For example, the Division for Children and Youth with Special Health Needs (DCYSHN) Medical Review Team (MRT), which screens all children for whom placement is sought in a pediatric skilled nursing facility (SNF) to ensure they meet strict medical and cognitive criteria, only serves the most vulnerable families. For those children with medical complexity not eligible for MRT and due to limited space in the state’s two SNFs, families would benefit from more available respite options; they are burnt out, having taken on an unprecedented amount of caregiving responsibilities during the pandemic. The DCYSHN participates on the state’s Lifespan Respite Coalition to work on these needs as well. MDPH will continue to assess strengths and gaps in services for the MCH population during the COVID-19 recovery.

Mental health workforce

During the 2020 needs assessment, a frequently cited issue was an insufficient health workforce to meet the mental health needs of the MCH population, such as pregnant and postpartum people, LGBTQ youth, and youth and young adults with disabilities and special health needs. Mental health services can also be difficult to access due to long waitlists or providers not taking certain insurance. Central to the shortage is the lack of racial, linguistic, and cultural representation in the workforce. Providers often do not reflect the populations being served, and there is a need for workforce training about racism, implicit bias, and cultural sensitivity to improve capacity to serve diverse and marginalized populations in the state. This issue is exacerbated by the increase in mental health concerns resulting from the COVID-19 pandemic, as seen in the findings of the COVID-19 Community Impact Survey.

Title V will continue to refine its action plan to strengthen the capacity of the health system to promote mental health and emotional well-being, such as through education and training of providers and school personnel, promoting community social connectedness, and collaborating with MassHealth on policies including licensing and reimbursement of doulas and extending insurance coverage up to 12 months postpartum. In June 2021, MDPH also applied for HRSA’s Pediatric Mental Health Care Access Grant to enhance the MA Child Psychiatry Access Project’s (MCPAP) early childhood mental health capacity and provide training and resources to enable primary care providers to support the behavioral health needs of children under 6 years old and their families. MDPH would coordinate with the Department of Mental Health, the Office of Medicaid, and the Infant and Early Childhood Mental Health Policy Workgroup to ensure alignment within the behavioral health system.

Breastfeeding rates

In FY20, Massachusetts breastfeeding rates decreased and fall short compared to national prevalence and Healthy People 2020 goals. Moreover, disparities by race/ethnicity and socioeconomic status in breastfeeding outcomes including initiation, continuation, and exclusivity persist. According to the most recent CDC Breastfeeding Report Card (reflecting 2017 births), 80.7% of Massachusetts infants were ever breastfed compared to the national prevalence of 84.1% and the Healthy People 2020 goal of 81.9%. In addition, 58.1% of infants were reported as breastfeeding (in any amount) at six months, compared to the national average of 58.3% and the Healthy People 2020 goal of 60.6%. Although these decreases are not statistically significant, these data merit further exploration and renewed focus on how to promote breastfeeding across Title V programs. See the Infant Health domain for FY20 activities and FY22 plans to increase the percentage of infants who are ever breastfed and who are breastfed exclusively through 6 months.

Agency and Program Capacity

Organizational Structure, Leadership, and Staffing

MDPH is part of the Executive Office of Health and Human Services (EOHHS), where legal, human resources, and information technology are centralized. The EOHHS Secretary reports to the Governor. The Bureau of Family Health and Nutrition (BFHN) within MDPH is the Title V Agency, with overall responsibility for the Title V program and funds. The BFHN Director is also the Title V Director, a senior manager who reports to the Associate Commissioner of MDPH. A sister Bureau within MDPH, the Bureau of Community Health and Prevention (BCHAP) also includes MCH-related programs. BFHN and BCHAP work closely on many initiatives, including the Needs Assessment and annual Title V reporting. The Childhood Lead Poisoning Prevention Program and Office of Health Equity are also significant components of Title V and reside in the Bureau of Environmental Health and the Office of Population Health, respectively.

Over the past year, the MA Title V program saw significant leadership changes. In January 2021, Elaine Fitzgerald Lewis became the Title V Director and Director of BFHN, following the departure of Craig Andrade in May 2020. Dr. Fitzgerald Lewis most recently held positions at the Education Development Center, Boston University School of Public Health, and the National Initiative for Children’s Healthcare Quality. In addition, Alison Mehlman, the BFHN Deputy Director and interim Title V/BFHN Director transitioned to become the Deputy Chief Operating Officer of MDPH in January 2021. Aaron Beitman is currently serving as the Acting Deputy Director. Further information about the Title V Partnership senior management team and their qualifications is provided in Attachment 2.

The organizational charts for BFHN and BCHAP are below and show the divisions and programs within each bureau. In January 2021, BFHN’s Office of Data Translation became the Division of Maternal and Child Health Research and Analysis. This new name clarifies what the division is responsible for and recognizes the breadth of its work. A MDPH organizational chart is attached, which shows the location of BFHN and BCHAP within the Department.

As of May 2021, approximately 188 full-time equivalent (FTEs) employees throughout MDPH work on Title V Partnership programs, with 107 FTEs paid from Title V Partnership funds. Approximately 21 of the Partnership-funded total are based in the MDPH regional offices or other off-site locations. There are approximately 81 FTEs working on MCH programs but paid through other federal grants. In addition, BFHN employs over 13 parents of children and youth with special health needs for the EI Parent Leadership Project, Family TIES, and Universal Newborn Hearing Screening Program. Additional details about how parents, families, and youth are involved in Title V programming are provided in the State Action Plan, Family Partnerships, and Attachment 3.

The share of total staffing supported by Title V remains stable due to successful efforts to cost-share staff with other federal discretionary grants. These totals and percentage distributions may continue to change during FY22 as efforts continue to bring the Title V budget into a more secure long-term equilibrium. The staff support may also be affected by the loss or reduction of federal discretionary grants.

Partnerships, Collaboration, and Coordination

MDPH is committed to building, strengthening, and sustaining partnerships with other organizations to better serve the MCH population and expand the capacity and reach of the Title V program. MDPH collaborates with families, public and private sector entities, federal, state and local government programs, clinical providers, academia, and public health organizations. The Family Partnerships section and Attachment 3 describe Title V’s partnership with families. Attachment 4 describes partnerships with external organizations, including government agencies, universities, and public health organizations and MCH programs within MDPH. These partnerships, collaboration, and coordination give depth and effectiveness to the MA Title V program and are integral to daily operations.