Introduction

The federal Maternal and Child Health Bureau (MCHB) is part of the Health Resources and Services Administration (HRSA), within the United States Department of Health and Human Services (HHS). Founded in 1912 as the Children’s Bureau, the MCHB has evolved over 110 years in response to the changing needs of mothers, children and families and shifting legislative and administrative priorities. MCHB is the only federal agency solely focused on improving the health and well-being of all of America’s mothers, children, and families.

Much has been written about the formation and early years of the Bureau (initially the Children’s Bureau) (200 Years of Children, 1977; Hutchins, 1994; Lesser, 1985; Lindenmeyer, 1997; Schmidt, 1973). The intent of this article, as part of this special supplement on MCH history, is to provide a brief overview of the Bureau’s earlier history, with more focused attention on changes from the 1980s changes in Title V to the present.

1912-1930s: The Early Years of the Children’s Bureau, Sheppard-Towner, and Title V

Organized efforts to promote and improve child health were nearly non-existent in the end of the nineteenth and beginning of the twentieth centuries. The plight for children was indeed poor, with children as young as seven frequently working in dangerous conditions, including textile mills and factories (Schmidt, 1973). Progressive Era advocates began to recognize the need for government-supported efforts to improve child welfare. Advances in knowledge of pediatric and obstetrical care in the latter half of the nineteenth century highlighted great opportunity for improving maternal and child heath through clinical care (Schmidt, 1973). As public health agencies started to develop at the state and local levels during this time, efforts focused on improving child health were also nascent, with the development of milk stations and creation of the first child hygiene unit in a public health agency (Lesser, 1985; Schmidt, 1973). Alongside growing community-based efforts to advance social welfare, such as the settlement house movement, the push for a national Children’s Bureau began.

Early legislative efforts to establish a Children’s Bureau were unsuccessful, with legislation proposed for six years prior to the final approval when the Bureau was authorized in statute on April 9, 1912. The Children’s Bureau was appropriated $25,640 and authorized for 15 full time employees, plus a Bureau Chief to be appointed by the President (Bradbury & Eliot, 1956). Despite the limited budget and small staff, the Bureau was given a broad charge: “The said bureau shall investigate and report to the Secretary of Commerce and Labor, upon all matters pertaining to the welfare of children and child life among all classes of our people, and shall especially investigate the questions of infant mortality, the birth rate, orphanage, juvenile courts, desertion, dangerous occupations, accidents and diseases of children, employment, legislation affecting children in the several States and Territories. The chief of said bureau may from time to time publish the results of these investigations in such manner and to such extent as may be prescribed by the Secretary” (“The Children’s Bureau,” 1912). The first chief of the Children’s Bureau was Julia Lathrop, a social worker from Illinois who had worked in Chicago’s Hull House (Parker & Carpenter, 1981). The placement of the Bureau within the Department of Commerce and Labor reflected the early interests in protecting children from the harms of child labor. The Children’s Bureau would move to the Department of Labor in 1913, the first of ten moves over the next 80 years (Table 1) (Bradbury & Eliot, 1956).

Table 1 Organization of MCH programs within the Federal Government, 1912-present
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In the early years, activities of the Children’s Bureau included educating the public, with the “Infant Care” pamphlet (first published in 1914), “Baby Week Campaigns” (1917), and the “Children’s Year” (1918). Bureau staff advanced birth registration in communities across the country and convened key stakeholders around child health issues (including a series of regional conferences that led to the second White House Conference on Children) (Bradbury & Eliot, 1956; Schmidt, 1973).

The first funded federal-state partnerships for maternal and child health (MCH) programs came with the authorization of the Sheppard-Towner Maternity and Infancy Care Act in 1921 (Hutchins, 1994). Sheppard-Towner authorized grants to states to support public health approaches to improving maternal and child health, and throughout the 1920s, every city with a population greater than 100,000 developed a MCH unit (Schmidt, 1973). Amid a growing discontent with the role of the federal government in state and local health efforts, Sheppard-Towner was not reauthorized in 1929, effectively ending this first period of federal-state MCH partnerships. This concern was not entirely new; even the statute authorizing the Children’s Bureau in 1912 noted, “…no official, or agent, or representative of said bureau shall, over the objection of the head of the family, enter any house used exclusively as a family residence” (“The Children’s Bureau,” 1912). The work of the Bureau was criticized by some members of Congress, the American Medical Association (AMA), and even the Catholic Church as being over-reaching and aligned with “socialism” or “Bolshevism” (Hutchins, 1994; Schmidt, 1973). There were also supporters of the Bureau’s work, including the pediatric section of the AMA, which broke with the rest of the association and formed the American Academy of Pediatrics (AAP) due to the AMA’s opposition to Sheppard-Towner (Golden & Brosco, 2012; Lindenmeyer, 1997).

Though the end of Sheppard-Towner resulted in decreases in state MCH budgets, the work of the Children’s Bureau continued. Bureau staff described needs of MCH populations and outlined plans for optimal support, which would soon be incorporated into the Social Security Act (Lesser, 1985).

The Great Depression resulted in federal efforts to reduce the effects of poverty. The Social Security Act, passed in 1935, included Title V: Grants to States for Maternal and Child Welfare (“Social Security Act of 1935,” 1935). The formative work of the Children’s Bureau during the Sheppard-Towner era informed the state grants-in-aid for maternal and child health authorized under Title V. Title V added a new focus on “crippled children,” informed by the Bureau’s reports of the needs for this population and the variability in services across states (Lesser, 1985). The provisions for crippled children’s services included references to systems (not just providing care, but also case finding, and “other services and care”) as well as prevention (“…children who are crippled or who are suffering from conditions which lead to crippling.”) (Schmidt, 1973). The law required states to submit a plan for maternal and child health and crippled children’s services for approval by the Chief of the Children’s Bureau, setting the foundation for accountability of grant funds. The Title V statute, consistent with the broader interest in social welfare, also included provisions for child welfare, as well as aid for dependent families (“Social Security Act of 1935,” 1935).

In addition to the state grants-in-aid, which were allocated based on the state’s proportion of live births and required 1:1 matching, Congress authorized a second allocation (“B fund”) that was based on need and supported the Bureau’s efforts to address current and emerging needs for MCH populations (Lesser, 1985; “Social Security Act of 1935,” 1935).

1940-1970s: Emerging Priorities and an Evolving Bureau

During World War II, the Children’s Bureau administered the Emergency Maternity and Infant Care (EMIC) program, the first large scale public medical program in our nation’s history. EMIC provided prenatal care, labor and delivery care, and care for infants, with a focus on the families of enlisted service members in the lowest four pay grades (Eliot, 1944). Between 1943 and 1949, EMIC served approximately 1.5 million mothers and infants and at one point covered one in seven births in the United States (“Close of the EMIC Program,” 1949; Merriam, 1960). The experience of EMIC laid the foundation for future public coverage for pregnant women and children.

In the 1950’s, a growing recognition of the link between maternal health and childbirth outcomes led to additional funding for the Children’s Bureau to support clinical programs and projects focused on prevention and treatment of intellectual disabilities, and newborn screening for phenylketonuria (PKU) and other metabolic disorders (Lesser, 1985). As the science of heritable disorders advanced, the Bureau published information for healthcare providers and for the public about sickle cell disease in the mid-1960s (Health Resources and Services Administration, 2022e).

The Children’s Bureau’s support for MCH training and research was born during this era. In 1947, the Bureau funded the first MCH training programs in schools of public health. Additional programs in social work and adolescent health followed within the next decade (Athey et al., 2000). The first appropriations for research were in 1963 and focused on preventing and treating intellectual disabilities.

The passage of Medicaid in 1965 represented a major shift in the assurance of health care for maternal and child populations. While Medicaid focused on payment for health care services, Title V filled an important foundational gap by assuring that systems of care were in place to support maternal and child health. The Children and Youth (C&Y) demonstration projects, authorized with the 1965 amendment to Title V, supported comprehensive care (defined as including “screening, diagnosis, preventive services, treatment, correction of defects, and aftercare, both medical and dental”) and focused on children in low-income neighborhoods (“Social Security Amendments of 1965,” 1965). The definition of comprehensive care preceded the subsequent establishment of the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program in Medicaid in 1967 (“Social Security Amendments of 1967,” 1968). The 1965 Title V amendments also introduced new authorization for training “professional personnel for health and related care of crippled children, particularly mentally retarded children and children with multiple handicaps” (“Social Security Amendments of 1965,” 1965). These training grants would later become MCHB’s Leadership Education in Neurodevelopmental and Related Disabilities (LEND) program (Athey et al., 2000).

In the early to mid-1970s, comprehensive programs were established for the treatment of sickle cell disease and hemophilia (Health Resources and Services Administration, 2022e). Interest in genetic programs continued, with passage of the Genetic Diseases Act in 1976 and the subsequent creation of the Genetic Services Branch in 1978.

Longstanding interests in infant health continued during this period. Bureau staff supported studies of infant mortality at the local level and partnered with academic and governmental partners on research related to premature infants. The Bureau developed training programs and published guidance for physicians on the care of premature infants, and states used their MCH funds to train medical personnel on the care of premature infants. Special project funds from the Bureau supported regional centers to provide surgical care for children with congenital heart disease (Bradbury, 1962). The 1967 amendments to Title V included funding for the Bureau to support special projects for infant care as well as family planning (Health Resources and Services Administration, 1996). Bureau staff provided consultation on the development of national recommendations for regionalized perinatal care, and in 1976, the Bureau launched the Improved Pregnancy Outcome Projects to improve care before, during, and after pregnancy (Health Resources and Services Administration, 2022e; Koontz, 1984).

The Children’s Bureau was moved administratively several times during this period (Bradbury & Eliot, 1956; Hutchins, 1994). In 1946, the Children’s Bureau (without the child labor components) was transferred to the Social Security Administration’s Federal Security Agency. The Federal Security Agency was reconstituted in 1953 as the Department of Health, Education, and Welfare (DHEW). In 1963, the Bureau was transferred to the Welfare Administration within DHEW and then subsequently to the Social and Rehabilitation Service within DHEW in 1965. The Children’s Bureau, as it had existed to date, was discontinued in 1969. The child welfare components were transferred to the Office of Child Development, while the health programs (including the programs that exist in today’s MCHB) were moved within DHEW to the US Public Health Service’s Health Services and Mental Health Administration in a unit designated as Maternal and Child Health Services (Athey et al., 2000). Maternal and Child Health Services was reorganized into an Office of MCH and the Division of Clinical Services. The Division of Clinical Services was responsible for Title V set-aside projects. Both the Office and the Division were housed within the Health Services Administration’s Bureau of Community Health Services within DHEW (Athey et al., 2000). By the end of the decade, the Office of MCH and Division of Clinical Services would be reunited and housed in the newly-formed Department of Health and Human Services (HHS), after the educational functions of DHEW were split off into another department (Hutchins, 1994).

1980-2020s: Transformations in Government, a Growing Bureau

The Omnibus Budget Reconciliation Act (OBRA) of 1981 (OBRA ’81, PL 97−35) brought swee** changes to Title V. OBRA ‘81 consolidated the Title V maternal and child health and crippled children’s services programs into a MCH block grant, along with categorical programs from the Public Health Service Act: lead-based paint poisoning prevention, sudden infant death syndrome, hemophilia treatment, and adolescent pregnancy grants (“Omnibus Budget Reconciliation Act of 1981,” 1981).

The OBRA ’81 authorized “special projects of regional and national significance (SPRANS), research, and training with respect to maternal and child health and crippled children, for genetic disease testing, counseling, and information development and dissemination programs, and for grants relating to hemophilia.” SPRANS funding would subsequently support some initiatives that had been categorically funded before the conversion to a block grant (e.g. genetics and hemophilia) as well as many other important future national MCHB initiatives.

The Title V amendments in OBRA ’81 also mandated the creation of “an identifiable administrative unit with expertise in maternal and child health within DHHS,” and MCH functions were organized in 1982 as the Division of Maternal and Child Health, part of the Bureau of Health Care Delivery and Assistance within the Health Resources and Services Administration (HRSA) (Hutchins, 1994). From 1987 to 1990, MCH programs in HRSA were located within the Bureau of Maternal and Child Health and Resources Development; this Bureau housed MCH projects as well as the Divisions of Organ Transplantation; Acquired Immune Deficiency Syndrome (AIDS) Service programs; Facilities Compliance; Facilities Assistance and Recovery; and Facilities Loans. At that time, the Bureau had responsibility for the new federal AIDS programs as well as the Hill-Burton facilities program, hospital mortgage insurance, and federal hospital construction loan programs (Health Resources and Services Administration, 1988). The Maternal and Child Health Bureau, as a distinct bureau within HRSA (and closest to the composition of the current Bureau), was established in 1990 (Athey et al., 2000).

OBRA ’89 (PL 101–239) brought an increased focus on accountability for federal funds, including a requirement for a statewide needs assessment every 5 years. MCHB recognized the need to better support states, and the field broadly, in develo** capacity to gather and analyze MCH data to inform programming and demonstrate impact. MCHB had already laid a foundation here through partnership with the Centers for Disease Control and Prevention (CDC) in 1986 to create the Maternal and Child Health Epidemiology Program (MCHEP). The MCHEP fosters collaboration between CDC and HRSA and builds state capacity through placement of MCH epidemiologists in states (Kroelinger, 2012; Rochat, Atrash, & Handler, 1999). In 1993, MCHB launched the State Systems Development Initiative (SSDI) to support state Title V and CYSHCN programs to build data capacity and infrastructure (Health Resources and Services Administration, 2017b). MCHB subsequently developed a performance measurement framework for the MCH Block Grant in 1997. The framework included State and National Performance Measures, National Outcome Measures, and measures of health systems capacity and health status for MCH populations (Kogan et al., 2015).

OBRA ’89 also stipulated that states spend at least 30% of their block grant funds for preventive and primary care services for children, and at least 30% for services for children with special health care needs (“Omnibus Budget Reconciliation Act of 1989,” 1989). The Bureau’s longstanding commitment to improving services for CSHCN was further solidified by additional text within OBRA ’89, which specifically described “family centered, community-based, coordinated care…for children with special health care needs” as well as “…the development of community-based systems of services for such children and families.”

The Block Grant changes for CSHCN populations occurred amidst a time of change for MCH efforts for these children. The new term “children with special health care needs” (CSHCN) was coined by Surgeon General C. Everett Coop in 1987. The Surgeon General’s Report on Children with Special Health Care Needs elevated the unique needs of CSHCN and recommended improvements for care systems, financing, research, and training (U.S. Department of Health and Human Services, 1987). MCHB subsequently published a new definition for CSHCN: “Children with special health care needs are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally” (McPherson et al., 1998).

During the 1980s, MCHB increasingly emphasized the importance of engaging families in the care of CSHCN. This focus was enhanced by the OBRA ’89 requirements for family-centered care. In addition to building requirements for family engagement and family-centered care into MCHB programs, the Bureau provided funding to Family Voices to support state organizations of family leaders to provide information to families, professionals, and policymakers (Anderson & Wells, 2005). Family Voices had been organized in the early 1990’s because families of CSHCN were concerned that their voices were not heard during health reform efforts (National Center for Education in Maternal and Child Health, 2021).

New programs were added during this era to build community capacity to care for children. The Bureau implemented programs related to genetics research and training as well as screening, diagnosis, and treatment of a variety of genetic conditions, including a thalassemia program in 1981 and regional genetics networks in 1983. The Emergency Medical Services for Children (EMSC, PL 98–555) program was first authorized in 1984 to address deficiencies in emergency care for children (Adirim, 2015; Fuchs, 2021). EMSC initially provided demonstration grants to four states but subsequently expanded to fund all states, DC, five territories, and three freely associated states (Fuchs, 2021). In 1986, the behavioral pediatrics training program (that would later become the Developmental Behavioral Pediatrics Training Program) was launched to support providers in addressing the behavioral and emotional health needs of children. The program supported fellowship training, as well as “collaborative office rounds” to connect academic programs with community providers (Athey et al., 2000).

Efforts by the Bureau to improve birth outcomes persisted during this time. The Bureau supported multidisciplinary training programs that provided training on caring for newborns with respiratory distress syndrome. The Bureau continued to fund IPO projects, and states used Block Grant funds to support newborn screening, neonatal intensive care, and neonatal transport programs (Koontz, 1984). MCHB established the Infant Mortality Review program, which would later grow into the National Fetal and Infant Mortality Review program (Koontz et al., 2004). The Healthy Mothers, Healthy Babies Coalition was formed in 1981 following a Surgeon General’s Conference on Infant Mortality. HMHB represented a public-private partnership focused on improving maternal health and prenatal care (Arkin, 1986). These efforts, along with subsequent national reports on prematurity and the content of prenatal care, laid the foundation for the launch of MCHB’s Healthy Start program. Healthy Start began in 1991 as a community-based initiative to reduce infant mortality and address racial disparities in birth outcomes (Escarne et al., 2017). The Secretary’s Advisory Committee on Infant Mortality (often referred to as SACIM), staffed by MCHB, was established in the same year to advise the HHS Secretary on programs directed at reducing infant mortality, initiatives to improve the health of women and infants, and the Healthy Start program (Health Resources and Services Administration, 2021a).

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PL 104–193) authorized a new abstinence education grant program. Congress appropriated $50 million in FY 1998 to support state formula grants for abstinence education programs that met an eight-point definition as outlined in statute (Health Resources and Services Administration, 2000). This program was reassigned to the Administration for Children and Families, Family and Youth Service Bureau in FY 2005 (Administration for Children and Families, 2005).

In the first decade of the new millennium, Congress formally authorized programs established earlier in the Bureau, including heritable disorders and Healthy Start (PL 106–310), and sickle cell disease treatment demonstrations (PL 108–357); Congress also authorized new programs for universal newborn hearing screening (PL 106–310) and autism (PL 109–416) (“American Jobs Creation Act of 2004,” 2004; “Children’s Health Act of 2000,” 2000; “Combating Autism Act of 2006,” 2006). MCHB continues to fund programs under these authorities that increase access to care, educate providers and families, and build comprehensive service systems.

Around the same time, MCHB hosted the first meeting of the Advisory Committee on Heritable Disorders and Genetic Disease in Newborns and Children. The Committee was established a few years after MCHB funded the AAP to convene a national task force on newborn screening. The charge of the Advisory Committee was to review and report on newborn and childhood screening practices, recommend improvements, and advise the HHS secretary on related programs and policies (Health Resources and Services Administration, 2020; Howell & Lloyd-Puryear, 2010).

The Patient Protection and Affordable Care Act (ACA), passed in 2010, ushered in important health provisions for MCH populations, including expansion of Medicaid eligibility, coverage under parental insurance plans for young adults up to age 26, and prohibition of exclusions for pre-existing conditions (“Patient Protection and Affordable Care Act,” 2010). The ACA also included important preventive care provisions for MCH populations. Section 2713 requires coverage by most insurers, without cost-sharing, for preventive services for infants, children, adolescents, and women. The ACA requires HRSA to support comprehensive preventive services guidelines for infants, children, and adolescents (the Recommended Uniform Screening Panel, RUSP; and the Bright Futures periodicity schedule); and women (the Women’s Preventive Services Guidelines).

The ACA also amended Title V of the Social Security Act to include Sect. 511, which authorized the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program (“Patient Protection and Affordable Care Act,” 2010). MIECHV supports voluntary, evidence-based home visiting for families in communities at risk of poor maternal and child outcomes. Similar to the Title V MCH Services Block Grant, MIECHV awardees are required to base plans for service delivery on a needs assessment, and state home visiting programs must periodically demonstrate improvement in four of six legislatively-mandated benchmark areas.

With the passage of the ACA and the ensuing expansions of coverage, funding cuts threatened the MCH Block Grant, which was recognized for serving as a payer of last resort for direct medical services (Lu et al., 2015). The availability of insurance coverage was necessary, but not sufficient alone, to improve the health of MCH populations. In 2015, in part due to pressures to demonstrate the continued need for the MCH Block Grant, the Bureau announced a transformation of the Block Grant Guidance. The overhaul was based on three principles: reduce burden on states, maintain state flexibility, and improve accountability (Lu et al., 2015). The new guidance featured an updated performance measurement framework, which included national outcome measures (NOMs, the ultimate health outcome to be improved), national and state performance measures (NPMs and SPMs, more proximal measures that demonstrate progress toward achieving the NOMs), and evidence-based/informed strategy measures, which describe progress for activities in the state’s action plan.

Much like the emergence of the C&Y projects following the creation of Medicaid, the Bureau recognized the need to support states in maximizing the benefits of the ACA for MCH populations. MCHB established the National MCH Workforce Development Center to provide the skills and knowledge needed by Title V leaders and staff to engage in health reform and public health transformation. While reform efforts looked different across states, common skills in four key areas were needed to support transformation: access to care, quality improvement, systems integration and population health management (change management) (Margolis et al., 2017).

MCHB has continued to lead the field in addressing the underlying determinants of health and well-being among MCH populations. In 2010, Bureau leadership commissioned a publication to bring attention to the life course theory and highlight implications for MCH programming (Health Resources and Services Administration, 2010; Pies & Kotelchuck, 2014). The life course theory recognizes the vital role of social, economic, and environmental factors in influencing health outcomes, including health inequities (Lu & Halfon, 2003). MCHB’s integration of a life course approach into multiple programs—including MIECHV, Healthy Start, research networks, and even the revised Title V framework—has furthered the Bureau’s longstanding work to address health inequities.

MCHB has utilized SPRANS funds to achieve efficiencies at a national scale (e.g., funding national technical assistance centers to support projects across multiple states or communities), to support core MCH infrastructure (e.g., grants for research and training, surveillance through the National Survey of Children’s Health) and for emerging issues (e.g., funding to support response to Zika virus and the COVID-19 pandemic) or special projects (e.g., collaborative improvement and innovation networks, CoIINs). Starting in 2012, MCHB initiated a CoIIN focused on strategies to reduce infant mortality (reducing early elective deliveries, expanding access to interconception care, promoting safe infant sleep practices, reducing smoking in pregnancy, and improving regionalized system of risk-appropriate perinatal care) (Hirai et al., 2018).

MCHB launched the National Survey of Children with Special Health Care Needs in 2001 and the National Survey of Children’s Health (NSCH) in 2003 to provide state- and national-level data on key indicators to inform MCH programming and policy (van Dyck et al., 2004). These surveys were each conducted every four years until 2016, when the surveys were combined into a single, annual survey (Ghandour et al., 2018). The NSCH is the only annual survey, representative at the state and national levels, of a variety of data on child health and corresponding family, neighborhood, and systems indicators. NSCH data inform 19 Title V NPMs and NOMs and 15 key Healthy People objectives (Child and Adolescent Health Measurement Initiative, 2021; Healthy People 2030).

MCHB has also contributed to the growth of the MCH epidemiology field through workforce development initiatives including the Graduate Student Intern Program, the MCH Epi Doctoral Fellowship program, and the MCH Epidemiology Training Course. These efforts have grown local, state, and tribal capacity for MCH data collection and analysis (M. Kogan, personal communication, January 6, 2023). MCHB has also invested in expanding MCH data through the MCH Jurisdictional Survey (launched in 2019 to provide 8 freely associated states and territories with data for their Block Grant application) and the National Survey of Children’s Health Longitudinal Cohort, which will assess the impact of the COVID-19 pandemic on the health and well-being of children (M. Kogan, personal communication, January 6, 2023).

The Bureau has also piloted new initiatives that would later obtain specific Congressional authorization and/or appropriations. For example, the Family to Family Health Information Centers (F2F HICs) were originally funded in 2005 as a SPRANS pilot to provide support, training, and resources to families and providers (Health Resources and Services Administration, 2017c). The F2F HIC program was subsequently authorized as a distinct section in Title V in 2006 (PL 109–171) (“Deficit Reduction Act of 2005,” 2006). Similarly, in 2014 MCHB launched the Alliance for Innovation on Maternal Health (AIM) using SPRANS funds (Health Resources and Services Administration, 2017d). AIM focused on improving safety in maternal care settings using “bundles”—actions to reduce mortality and morbidity. As interest in maternal health grew over the next few years, Congress specifically appropriated $3 M for AIM in SPRANS in 2018 (House of Representatives, 2018). By 2023, the Congressional appropriation for AIM grew to $15.3 M (Congressional Record, 2022).

Congress has, at times, specifically set aside SPRANS funds for particular topics. For example, in the FY 2023 budget, Congress set aside funds for oral health, epilepsy, sickle cell disease, and fetal alcohol syndrome (Congressional Record, 2022). Over the last four years, the SPRANS appropriations for maternal health have noticeably increased, with funding for state maternal health innovation grants, minority-serving institution research networks, and a maternal mental health hotline. In FY23, maternal health appropriations in SPRANS totaled $72 M (Congressional Record, 2022).

Congress has also assigned new programs to MCHB. In 2016, the 21st Century Cures Act (PL 114–255) authorized two programs aimed at improving access to behavioral health services for MCH populations: the Pediatric Mental Health Care Access Grants and Screening and Treatment for Maternal Depression (“21st Century Cures Act,” 2016). These programs were modeled after pilot programs in Massachusetts (Byatt et al., 2016; Sarvet et al., 2010). and helped to address increases in behavioral health diagnoses among children as well as pregnant/postpartum women.

MCHB has adapted not only to broad, gradual changes in the field, but also to rapidly-evolving issues impacting MCH populations. In 2016, the first cases of locally-transmitted Zika virus were identified in the United States (National Institute of Allergy and Infectious Diseases, 2022). Prenatal exposure to the mosquito-borne Zika virus can result in serious birth defects, including microcephaly and severe brain malformations (Shapiro-Mendoza et al., 2017). MCHB awarded $20 million in grant funds to assure access to comprehensive services, educate providers on caring for children with Zika virus, and support family engagement (Health Resources and Services Administration, 2017a). As a result of Zika funding, public health departments in Puerto Rico, U.S. Virgin Islands and American Samoa received funding to ensure access to services for infants and children born to mothers who tested positive for Zika. Funds also supported workforce development and new family engagement efforts. In 2017, in response to lead exposure from contamination of the public water supply in Flint, Michigan, MCHB awarded a $15 million supplement to the Genesee County Health Department’s Healthy Start program (Health Resources and Services Administration, 2017e). The supplemental funding supported identification of more than 9600 children who experienced lead exposure, and referral to appropriate community resources and support services (including Medicaid, WIC, and early intervention services) (D. Levinson, personal communication, April 18, 2022).

The global COVID-19 pandemic, starting in 2020, had far-reaching impacts on MCH populations. Pregnant women with COVID-19 experienced increased likelihood of admission to intensive care units, and increased morbidity and mortality (Zambrano et al., 2020). Children missed routine preventive care, including well-child visits and immunizations (Lebrun-Harris et al., 2022). Families experienced increased hardships, such as loss of employment and disruptions in child care (United States Census Bureau, 2022). Through the Coronavirus Aid, Relief, and Economic Security (CARES) Act of 2020, MCHB issued $15 million in grant awards to support telehealth with a focus on four areas: maternal health; infant, child, and adolescent health; family engagement; and public health services and systems (with a specific focus on newborn screening and home visiting) (U.S. Department of Health and Human Services, 2020).

The Bureau utilized SPRANS funds to support a prize challenge competition to incentivize community partnerships to increase well-child visits and immunizations. Through the Promoting Pediatric Primary Prevention (P4) Challenge, community partners generated more than 52,000 well-child visits and nearly 23,000 immunizations (U.S. Department of Health and Human Services, 2022b). In response to increased behavioral health concerns during the COVID-19 pandemic, the American Rescue Plan Act authorized an additional $80 M in funds to expand the program to additional states (“American Rescue Plan Act of 2021,” 2021; Jones et al., 2022; Radhakrishnan et al., 2022). The FY 2021 appropriations for MCHB also included $10 M in SPRANS funding to create a new regional pediatric pandemic network to coordinate among pediatric hospitals and communities in preparing for and responding to global health threats (House Committee on Appropriations, 2020).

MCHB Today

With deep roots going back to the Progressive Era, today’s Maternal and Child Health Bureau continues the tradition of promoting the health and well-being of mothers, children, and families. MCHB manages fourteen distinct legislative authorities (Table 2) with a budget of $1.68 billion in federal fiscal year 2023. The Bureau is staffed by over 300 full-time employees working in six programmatic divisions and three cross-cutting offices (Table 3). Divisions include: Child, Adolescent and Family Health; Healthy Start and Perinatal Services; Home Visiting and Early Childhood Systems; MCH Workforce Development; Services for Children with Special Health Care Needs; and State and Community Health; offices include Epidemiology and Research; Policy and Planning; and Operations Management. The Poison Control Program, previously housed in HRSA’s Healthcare Systems Bureau, was transferred to MCHB in 2021 and is housed in the Division of Child, Adolescent and Family Health alongside MCHB’s injury prevention programs (Health Resources and Services Administration, 2021b). The Poison Control Program had originally been housed within MCHB when it was first established at HRSA in the early 2000s (The Institute of Medicine, 2004).

Table 2 MCHB Current Legislative Authorities (as of 2023)
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Table 3 MCHB Programs, by Division (as of 2023) b
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MCHB’s three largest programs have substantial reach across MCH populations. The Title V MCH Services Block Grant reaches 98% of all infants, 93% of pregnant women, and 60% of all children, including children and youth with special healthcare needs (Health Resources and Services Administration, 2022a). MIECHV has provided over 8 million home visits since 2012. In FY2021, MIECHV services were available in 1065 counties, across all 50 states, five territories, and the District of Columbia, with the majority of participants living at or below the federal poverty level, nearly a quarter of all adult participants having a high school education or less, and 20% of households reporting a history of child abuse or maltreatment (U.S. Department of Health and Human Services, 2022a). In FY2020, Healthy Start reached approximately 66,000 participants in 101 communities with some of the highest infant mortality rates in the country. The current Healthy Start cohort has projects in 35 States, the District of Columbia, and Puerto Rico (U.S. Department of Health and Human Services, 2022a).

Bureau-funded investments continue to provide critical MCH infrastructure in research, training, technical assistance, and focused topics. MCHB supports interdisciplinary MCH public health workforce training programs at the undergraduate, graduate, and post-graduate levels along with specialized training for nutrition, pediatric pulmonary care, and adolescent health. Across MCHB-funded training programs, 82% of trainees still serve MCH populations at 5 years post-training, and 93% demonstrated leadership in MCH at 5 years post training (Maternal and Child Health Bureau, 2022). The Bureau supports investigator-initiated and secondary research on a variety of MCH topics and supports research networks on autism, CSHCN, pediatric and obstetrical care, and special MCH topics (e.g., life course). MCHB-funded research grants support an average of 140 peer-reviewed publications annually, building the evidence base for MCH practice and policy (Health Resources and Services Administration, 2022d). The National Survey of Children’s Health, in addition to its vital role in describing Title V performance measures, influences health policy in the public and private sectors. NSCH data are cited in the America’s Health Rankings “Health of Women and Children Report” as well as the Robert Wood Johnson Foundation’s reports on childhood obesity; in 2018, Starbucks cited NSCH data in announcing a new child and adult care benefit for its employees (Robert Wood Johnson Foundation, 2021; Starbucks, 2018; United Health Foundation, 2021). MCHB also supports a variety of technical assistance projects focused on topics ranging from safe sleep to school-based health to systems of care for CSHCN.

MCHB continues to provide national leadership for engaging families and individuals with lived experience in program planning, design, implementation, and evaluation. States report on family and consumer engagement in their Block Grant annual report and application, and MCHB not only funds the F2FHICs but also technical assistance centers to promote family leadership and engagement. MCHB continues to staff two federal advisory committees—the Advisory Committee on Heritable Disorders and the Advisory Committee on Infant and Maternal Mortality—and in addition to public health and clinical experts, both committees include family or consumer representatives as voting members.

The HRSA-supported preventive services mandated in the ACA have far-reaching impacts for MCH populations. HHS estimated that in 2020, 37.1 million children and 58.0 million women covered by private insurance had access to preventive services without cost sharing (Office of the Assistant Secretary for Planning and Evaluation, 2022). Over 30 million children covered under Medicaid benefit from Early, Periodic, Screening, Diagnosis and Treatment (EPSDT) services without cost-sharing (Office of the Assistant Secretary for Planning and Evaluation, 2022). Thirty-three Medicaid agencies in the states, DC, and territories have adopted the MCHB-supported Bright Futures periodicity schedule as their EPSDT periodicity schedule (Administration for Children and Families, 2022). And among the 35 newborn screening core conditions currently on the Recommended Uniform Screening Panel, all 50 states, DC, Guam, and Puerto Rico are screening for at least 30 or more conditions; eighteen states screen for all 35 core conditions (Association of Public Health Laboratories, 2022).

MCHB partners with other agencies across HHS that serve MCH populations. The 1967 amendments to Title V added requirements for collaboration with Title XIX (Medicaid), and OBRA ’81 added requirements for collaborating with the Departments of Agriculture and Education as well as other health programs (“Omnibus Budget Reconciliation Act of 1981,” 1981; “Social Security Amendments of 1967,” 1968). As part of their annual MCH Services Block Grant report/application, states submit a current interagency agreement outlining the relationship between the state Title V and Medicaid programs. MCHB routinely engages other HHS partners (Centers for Medicare and Medicaid Services, Centers for Disease Control and Prevention, National Institutes of Health, Administration for Children and Families, Administration for Community Living, and Substance Abuse and Mental Health Services Administration) through program-specific collaborations, participation in advisory committees, and ad-hoc consultation on emerging issues. Recognizing that non-health determinants also influence the health and well-being of children and families, MCHB regularly partners with the Departments of Agriculture, Education, and Housing.

In 2021, MCHB released an updated Strategic Plan to guide Bureau activities over the next decade (Health Resources and Services Administration, 2022c). The plan focuses on four key goals: (1) Assure access to high-quality and equitable health services to optimize health and well-being for all MCH populations; (2) Achieve health equity for MCH populations; (3) Strengthen public health capacity and workforce for MCH; and (4) Maximize impact through leadership, partnership, and stewardship.

MCHB’s strategic goal on equity aligns with a key priority of the broader MCH field as well as the strategic plans of HHS and HRSA (Association of Maternal and Child Health Programs, CityMatCH, National Healthy Start Association, & National Institute for Children’s Health Quality, 2021; Health Resources and Services Administration, 2022b; Jackson et al., 2020; U.S. Department of Health and Human Services, 2022c). MCHB is working to better integrate equity into all funding opportunities as well as into internal organization practices. Since 2020, MCHB leadership has supported a staff-led workgroup focused on equity and inclusion, a cross-bureau workgroup focused on infusing health equity into programming, and the creation of a new Senior Advisor for Health Equity position.

Conclusion: We Continue to Move into the Traffic

From 1912 until now, eleven leaders have guided the work of the Bureau, alongside scores of maternal and child health professionals (Table 4). The work of the Bureau has not always been met with applause. During the Sheppard-Towner debates of the 1920’s, one US Senator described Bureau leadership and staff as “spinsters who wanted to control maternity and teach mothers how to rear babies” (Costin, 1975). Reflecting on the EMIC Program in the middle of the last century, the AMA’s Council on Medical Service noted: “No more should the Children’s Bureau be the oracle to which all must turn and bow for guidance in every procedure” (“Medical Services to Dependents of Servicemen,” 1952). Yet others have lauded the work, describing the Bureau as “the defender of America’s children, not just the poor and neglected, but all children, all families. Judges, statesmen, clubwomen, church leaders, politicians, leaders in all walks of life were its champions” (Baumgartner, 1962).

Table 4 Bureau Leadership, 1912-present
Full size table

Over 110 years, Bureau staff have provided national leadership and supported marked improvements in outcomes for MCH populations. Following in the legacy of pioneering and persevering leaders, MCHB will continue—in the words of Grace Abbott, second chief of the Children’s Bureau—to move “into the traffic” to advance the cause of improving the health and well-being of all of America’s mothers, children and families.

“Sometimes when I get home at night in Washington, I feel as though I had been in a great traffic jam. The jam is moving toward the Hill where Congress sits in judgment on all the administrative agencies of the Government. In that traffic jam there are all kinds of vehicles moving up toward the Capitol. There are all the kinds of conveyances, for example, that the Army can put into the street—tanks, gun carriages, trucks, the dancing horses of officers…the hayricks and the binders and the ploughs that the Department of Agriculture manages to put into the streets…the handsome limousines in which the Department of Commerce rides…the barouches in which the Department of State rides with such dignity…I stand on the sidewalk watching it become more congested and more difficult, and then—because the responsibility is mine and I must—I take a very firm hold on the handles of the baby carriage and I wheel it into the traffic.” Grace Abbott, 1931 (Sorensen, 2008).