Building New Foundations to Promote Maternal and Child Equity and Improved Outcomes

Maternal and child health (MCH) providers and leaders across the country responded with great agility in service and support of families during these times of crisis. This was no easy task given that state MCH programs have responsibility for many programs seeking to ensure the health and well-being of women and children. Most state MCH agencies administer an array of programs including Title V Maternal and Child Health Services Block Grant, Maternal, Infant, and Early Childhood Home Visiting (MIECHV), Part C Early Intervention, Title X family planning, WIC nutrition services, immunizations, newborn screening, early childhood comprehensive systems, and other programs. 

State maternal and child health (MCH) programs have broad responsibilities but deliver few direct services. In this time of crisis, they provided support to public health and interagency efforts to keep systems safe and functional. Many state MCH programs had to: support home visiting, WIC, Part C Early Intervention, and other programs with COVID-related guidance, technical assistance, training, data, and oversight related to transitions to virtual service delivery; develop new COVID-related health and safety guidelines for schools, child care, and others; take an active role in supporting changes in perinatal regional systems and the birth settings/hospitals they oversee to ensure that pregnant women had safe and appropriate access to services at the time of birth; accelerate community-level early childhood comprehensive systems efforts; and support virtual delivery health care, while setting up safe spaces for infants and toddlers to be immunized in pediatric primary care, women to give birth, or sick children to receive needed health care.

Agencies not only responded quickly on multiple fronts, but did so innovatively, in partnership, and by leveraging flexible funding – dynamic efforts that merit a callout. In addition, this was achieved despite the fact that many MCH staff were deployed to other roles or dedicated time to participate in COVID-19 response teams in the larger health department. Debbie Chang, leader of a large California health foundation said: “People need to know the COVID-19 pandemic (s)heroes were not only in hospitals and child care; they also were in public health.

Innovations and Other Bright Spots to Carry into the Future

  • Maternal and Infant Health: MCH leaders focused on access to and quality of perinatal services to promote birth equity and they hope to sustain and grow these efforts, particularly through Perinatal Quality Collaboratives. Supporting women before, during, and beyond pregnancy in order to improve maternal and infant outcomes a primary aim. In Illinois, funding for the Chicago area "Masks for MOMS" project is noteworthy since Title V does not generally fund this type of collaborative, community-based coalition project.
  • Child Health Care Transformation: Many interviewed emphasized the importance the transformation of pediatric primary care for young children toward more holistic, family-centered, and high-performing medical homes. Dr. Andrew Hsi, who leads the Institute for Resilience, Health and Justice at the University of New Mexico stressed “…the importance of pediatric primary care that focuses on whole families, bringing together physical and behavioral health services, and care coordination.”
  • Engaging and Supporting Families: Engaging families and communities in planning, program development, and policy decisions is a longstanding priority for MCH programs. State MCH agencies have accelerated and will continue to support the development of leadership capacity in communities and to fund roles for family leaders at the state and local level. For example, based on changes started during the COVID-19 crisis, Louisiana is shifting toward a statewide system of family resource centers that can serve as hubs for overall family support via peer approaches.
  • Early Childhood Comprehensive Systems: Building stronger interagency relationships and early childhood systems is a high priority for the future. Massachusetts early childhood comprehensive systems lead Kate Roper stressed how we have learned during these times of crisis that: “Looking ahead we need to build community networks across silos and the mechanisms to spend flexibly in order to fill gaps and cracks in systems.”  “We've not been using resources well across systems, not leveraging, not maximizing capacity. Agencies try to reinvent the wheel or work beyond their strengths,” said Alicia Leatherman, Ohio’s administrator for home visiting and maternal and infant wellness programs.
  • Collaboration: All see the potential for public health to work more effectively with early care and education and other elements of the early childhood system, particularly regarding health guidelines and systems-building efforts. “Interagency collaboration is another element to carry into the future. Interagency collaboration is a constant challenge, but things seem better during the COVID crisis,” said Dr. Kenya McRae, Title V Director in Illinois. Louisiana’s Title V Director, Amy Zapata said: “The COVID-19 crisis has given us the three essential elements for effective collaboration: trust, time, and action together.” 

Sustaining Title V and Medicaid Funding is Key 
While state MCH agencies have a limited role in providing direct services, they play an essential role in anchoring and financing an array of services for women, children, and families. The Title V Maternal and Child Health Services (MCH) Block Grant is the core funder for all state MCH agencies. The flexibility of the Title V MCH Block Grant was vital to a rapid shift in response to the COVID-19 emergency. Many providers were able to shift to virtual services supported by flexible funding combined with public health agency guidance and staff support.  

Sustaining MCH agencies is essential as they must continue to guide health and safety decisions in health care, schools, and child care. MCH leaders inside and outside government said that they support the idea of sustaining financing and a workforce to deliver virtual services in combination with in-person services. State MCH agencies also support the development of leadership capacity in communities and fund roles for family leaders. At the state and local levels, this may involve continuing virtual listening sessions, engagement in systems development, parent-to-parent support staff, or other mechanisms. At the same time, MCH leaders expressed concern that budget cuts may limit their capacity to respond at a time when families continue to be in economic crisis, threatened by COVID-19, or experiencing racism. Many interviewees discussed the importance of sustaining funding and applying lessons learned. Ohio’s Title V director Dyane Gogan Turner added: “We need to move to public health 3.0, to gain new perspectives on the role of MCH agencies in coordination, state structures, and family outcomes.”

Interviewees discussed the important role of Medicaid in financing virtual services (e.g., home visiting, early intervention, prenatal care, and well-child visits) in assuring that virtual services were covered financially. Most commented on the important role of Medicaid now and in the future, of continuing and expanding coverage levels for parents and children. 

Equity: A Common Goal of MCH Leaders During the Pandemic and Beyond
Public health leaders give high priority to identifying and addressing issues of inequity, disproportionality, discrimination, and bias based on race, ethnicity, and social class through changes in MCH policies, programs, and care systems. MCH leaders strongly stated that we must continue to focus on equity and anti-racism. As described by Kenn Harris, the director of a Healthy Start technical assistance project at the National Institute for Children’s Health Quality (NICHQ): “In the big socio-ecological system, the driver is racism. It influences every other system.” 

In MCH, as in other areas of early childhood systems, a huge opportunity exists to use policies and programs to advance equity. Karin Downs said: “Title V in Massachusetts has been working on equity for at least five years. Now, the times call for government to look at every policy and consider it through an equity lens to determine whether the policy is exacerbating disparities. Dr. Janis Gonzales, Title V director for New Mexico, stated: “If programs such as Title V are intended to serve the whole population, people of color are part of the population. We have to be committed to change going forward, to understanding root causes, and to learning what to do.”

All of the five state MCH directors interviewed plan to use their state’s Perinatal Quality Collaborative as one mechanism to advance equity in birth outcomes. New Mexico is tackling unequal treatment of Native American pregnant women. Louisiana MCH leadership is committed to shifting attitudes and behaviors in the perinatal care system that may be based on discrimination due to race, ethnicity, and social class. As noted by Dr. Joia Crear Perry, founder of the National Birth Equity Collaborative: “What would it mean to focus on women's wellness and care outside of pregnancy across the life course, to move away from old ways of thinking and doing?” 

Because Medicaid finances approximately half of births, it plays a central role in improving equity in birth outcomes. Ohio will use new partnerships and payment approaches to support doulas, community health workers, and others on the care team. Dr. Mary Applegate, Ohio Medicaid Medical Director, said: “While it is difficult to change providers’ knowledge, attitudes, and behaviors in practice, the levers of QI and financing are key to doing so.” Overall, the recommendation is to stop doing QI projects that just measure disparities and use approaches designed to reduce disparities and to promote birth equity.

Engaging families and communities in planning, program development, and policy decisions is a longstanding priority for MCH programs but must be strengthened going forward with a greater focus on shifting power and advancing equity. Kenn Harris observed: "This is an opportunity to use the grassroots community connectors, to lift them up, and create permanent, paid roles for their efforts."

Key Recommendations
Every state has the potential to improve maternal, child, and family health services and to build new foundations that give existing systems the strength and capacity to better serve families today and withstand future crises. The following recommendations emerged from interviews with leaders from national organizations, tribes, and five states:

  1. Sustain the capacity of state MCH agencies to administer an array of programs that affect the health and well-being of women, young children, and families, including Title V and other funding.
  2. Continue use of Medicaid financing for an array of virtual services provided to women and children, along with adequate funding for in-person services and flexibility for providers to offer “catch up” well-child visits for immunizations, developmental screening, and parent support.
  3. Fund family engagement, community-level action, and early childhood systems development with flexible Title V dollars. 
  4. Monitor the quality and outcomes of changes in service delivery as a result of COVID-19, in line with the assurance function in public health and MCH agencies. 
  5. Use an equity lens to intentionally assess and review all program and policy decisions and make changes as necessary. 
  6. Leverage Perinatal Quality Collaboratives and oversight of perinatal systems to advance birth equity.
  7. Work with partners to accelerate child health care transformation toward more holistic, family-centered, team-based, high-performing medical homes for young children.  
  8. Contribute Title V and Medicaid funding to efforts to train and deploy a workforce of community health workers, doulas, family navigators, and others who provide care coordination and support to families. 
  9. Improve interagency collaboration focused on safety, quality, engagement, and equity for families with pregnant women and young children.

Moving Forward 
For 85 years, the Title V MCH Block Grant program has been the anchor supporting public health services to help pregnant women, infants, children, and adolescents. Through direct and enabling services, state Title V MCH agencies serve 20 percent of pregnant women, 36 percent of infants, and one in ten children. Medicaid finances about half of all births, covers more than 40 percent of infants and toddlers, and covers more than half of Black, Hispanic, and Native American children 0-18 years. The Medicaid Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) child health benefit covers a wide array of prevention, early intervention, and treatment services. Together, these programs are essential elements for building new foundations in the health of mothers and children prenatal to five. 

About the Author 

Over the past 35 years, Kay Johnson has become nationally recognized for her work in maternal and child health, as an advocate, researcher, and consultant. Reducing the impact of poverty and racism and increasing access for women and children are two of her lifelong goals. Kay is president of Johnson Group Consulting.  Her expertise encompasses a wide range of issues. Her work at the Children’s Defense Fund, March of Dimes, George Washington University, and Johnson Group helped to shape the direction of MCH and Medicaid policy since 1984.  Prior to her policy career, Kay worked with families in early care and education.