NPM 1: Percentage of women, ages 18 through 44, with a preventive medical visit in the past year
Objective 1. Increase the number of women returning for the postpartum visit from 87.3% in 2016-2018 to 96.0% in 2025.
Data:
According to the latest available Oklahoma Pregnancy Risk Assessment Monitoring System (PRAMS) data (2018 - 2021), 89.1% of new mothers in Oklahoma attended their postpartum visit. White mothers reported a higher postpartum visit rate (92.5%) than African American mothers at 82.9%, Native American mothers at 83.8%, and mothers who reported their race as Other at 87.1%. Rates increased slightly in all race/ethnicity categories however, no category reached the goal of 96.0% yet. With global billing and reimbursement for obstetric services, claims data were not available to support this self-reported percentage. As in previous years and based on anecdotal information, these numbers may be inflated by recall or social desirability bias, as mothers may have been aware they were expected to return for the postpartum visit but did not actually attend the visit.
Every county health department (CHD) utilized the Preconception Screening Tool with clients seen for an initial or annual exam and all clients with a negative pregnancy test desiring pregnancy. This tool is available in five languages: English, Spanish, Burmese, Marshallese, and Zomi. One request was received from a physician in Ohio for copies in all languages for use in their clinic.
Successes:
PRAMS data were used to create several publications including Electronic Cigarette Use Before Pregnancy and Breastfeeding Among Mothers with Preterm and Term Birth. Non-Hispanic White mothers less than 20 years old and mothers with an annual income less than $24,000 reported the highest rates of e-cigarette use before pregnancy. Just over 10% of Oklahoma babies were born preterm. Breastfeeding initiation was similar for term and preterm births. Non-Hispanic American Indian mothers with preterm births had the lowest rates of initiation and duration of breastfeeding and teen mothers who gave birth preterm reported breastfeeding rates significantly higher (95.1%) than those teens with a term birth (79.9%). These data support the need for continued education about preventive medical visits prior to pregnancy, early prenatal care, and attendance at postpartum visits.
The Soon-To-Be-Sooners Medicaid plan continued in the state but was a limited benefit plan with coverage ending at delivery; therefore, the postpartum visit was not covered. Consequently, women who qualified for this package may not have returned for their postpartum visit and health care providers were not motivated to encourage these mothers to return in the absence of medical conditions requiring follow-up. The Oklahoma Perinatal Quality Improvement Collaborative (OPQIC), the Maternal Health Task Force, and the Oklahoma Health Care Authority (OHCA) worked to support efforts to expand Medicaid postpartum coverage to 12 months, which became effective January 1, 2023. However, it did not apply to mothers covered under the Soon-To-Be-Sooners plan.
Enrollment opened June 1, 2021, for expanded Medicaid eligibility to adults ages 19-64 whose income was 138% (133% with a 5% disregard) of the federal poverty level or lower. Expansion offered the full benefit package for women before, during and after pregnancy. Annual report information is not yet available for FY2023 from OHCA.
CHD staff continued to encourage women to return to their delivering provider for a postpartum visit. For those women who refused to return to the delivering provider, the advanced practice nurse in the CHD conducted a postpartum visit, follow-up, or referral for follow-up, on any health conditions that developed during pregnancy (i.e., gestational diabetes, hypertension) and encouraged the use of the moderately or most effective methods of contraception as indicated through client-centered counseling.
Children First (C1), Oklahoma's Nurse-Family Partnership, continued to provide a voluntary family support program that offered home visitation services to mothers expecting their first child. Upon enrollment, a public health nurse worked with the mother in order to increase her chances of delivering a healthy baby. The nurses assessed clients in six domains during the prenatal period: Personal Health, Environment, Family and Friends, Life Course Development, Maternal Role, and Health and Human Services. During the C1 postpartum visit, the nurse asked when the client’s next appointment with the delivery provider was to occur. Visits from the C1 nurse were scheduled based on client’s need or desire, but typically were weekly for the first four visits; every other week until the baby is born: weekly during the first six weeks postpartum; every other week until the child is 21 months; and then monthly until the child turns two. Mothers were also asked, up to 12 weeks postpartum, if they had returned for a postpartum visit. These questions provided a natural segue to encourage the client to attend the postpartum exam. Visits were provided in the client’s home or location of client’s choice which could include clinic, virtual, telephone or other location.
Last year, all family planning (FP) clinics switched to using the Preconception Screening Tool that was developed as part of a Human-Centered Design project with the University of North Carolina. The tool was made available in five languages: English, Spanish, Burmese, Marshallese, and Zomi. This tool was used to start a conversation about preconception/interconception reproductive health and plans regarding future pregnancies to tailor client-centered care to the needs of each individual client. Staff took the opportunity to remind clients of the importance of returning for their postpartum visit (if applicable) and getting regular annual exams. An example of the Preconception Screening Tool is below.
FP clients with a positive pregnancy test continued to be counseled on the need to initiate care with a maternity health care provider within 15 days. Nine CHDs offered maternity services this year, increasing access to early prenatal care. For clients choosing to follow up with the CHD for prenatal care, the initial prenatal lab work could be drawn during the pregnancy test visit and an appointment scheduled with the APRN. One hundred forty-one clients received prenatal care through OSDH in this grant period. Most of them either returned to the delivery provider or did not attend the postpartum visit. However, 26 clients did return to the CHD for postpartum care. These gap-filling services were introduced to improve access to quality care closer to home and improve attendance at both prenatal visits and the postpartum visit.
OSDH advanced practice providers, nursing, and support staff continued returning to primary responsibilities post-COVID, but the Family Planning Annual Report (FPAR) showed a slight decrease in the number of clients seen for their annual preventive health visit from 25,961 during CY2022, to 25,123 in CY2023. With the loss of Title X FP funding in April and the change in 340B eligibility, clients were rescheduled when possible or offered a prescription from a pharmacy for their contraceptives/medications until a funding solution for the program from the State Legislature could be secured and 340B status returned.
Community Health Workers (CHW) received training including information on reproductive health services and how to link individuals to OSDH services and other reproductive health services in the community. Some CHWs were selected and began training as Perinatal Resource Navigators for the agency.
Challenges:
OSDH, in conjunction with partners at the OHCA and private insurers, continued to struggle with splitting the postpartum visits from the global package. Consequently, it remained difficult to determine how many women actually returned for their postpartum visit. Current information on postpartum visits was obtained from PRAMS, which relied on the mother’s recall and ability to have completed the postpartum visit at the time of the survey. On January 1, 2023, Medicaid expanded postpartum coverage to 12 months. However, data regarding utilization of this benefit is not available yet.
Even though Oklahoma did expand Medicaid, the limited benefit package for Soon-to-be-Sooners recipients continued to end at delivery so it did not cover the postpartum visit.
The lack of health care providers in rural areas made it difficult for some women to attend a postpartum visit due to limitations of time and transportation. Due to the large percentage of working mothers without paid leave, many new mothers were forced to return to work early, making it difficult to attend postpartum and newborn health care visits.
The sudden loss of Title X funds in late April 2023 essentially halted most FP visits until new protocols, procedures and funding sources could be identified. Visits were prioritized and rescheduled, when possible, for a few months. Fortunately, through collaborations between agency divisions and partners, other options were identified within 30 days. Contraceptive options were limited for a while but there was never a break in service delivery.
Objective 2. Improve birth intention by increasing the usage of the most effective methods of contraception among women with Medicaid and at risk for unintended pregnancy from 15.0% in 2018 to 20.0% in 2025.
Data:
Baseline data for SFY 2014 indicated 8.5% of females < 18 years, 16.3% of 19-24 years, and 14.7% of females > 25 with Medicaid-funded health care relied on long-acting reversible contraception (LARC) methods. Staff and reporting methods changed during the last reporting period and consequently, current data are not comparable to the baseline data. Data reported this year from the OSDH FPAR indicated that 83.1% of unduplicated clients were covered by Medicaid or considered uninsured. For the purposes of this report, the uninsured category includes individuals covered by SoonerPlan since it is not a full benefit plan. The FPAR for calendar year 2023 indicated 6.0% of all female clients relied on intrauterine devices/systems and 9.8% of female clients relied on the implant for contraception. This equates to 20.6% of all users and 23.8% of clients choosing a hormonal method of contraception relying on a LARC method. FP services were provided to a total of 25,123 females and males of reproductive age for calendar year 2023 (down slightly from 25,961 in CY 2022). Of the 25,123 clients, 11,630 relied on public insurance (down from 12,465 in 2022) and 9,254 were considered uninsured (SoonerPlan clients were included in the uninsured category for the purposes of FPAR since benefits were limited to only FP). There were three Title X grantees in the state and the statewide FPAR report released in September 2023 (for CY 2022) indicated that 29,239 unduplicated clients were seen statewide with 95% reporting incomes < 250% FPL. Using the same Medicaid definitions above, 76% were covered by public health insurance or uninsured. Of these 29,239 clients, 23% relied on a most effective method of contraception and 59% relied on a moderately effective method of contraception.
Successes:
OHCA continued provision of FP services through SoonerPlan, the state plan amendment (SPA) as well as expanded Medicaid services known as SoonerChoice. SoonerPlan provided coverage for uninsured men and women 19 years of age or older who were United States citizens or qualified aliens, residents of Oklahoma, not eligible for regular Medicaid, and who met the income standard. Services provided included: physical exams related to FP, birth control information, methods, and supplies; laboratory tests including pap smears and screening for sexually transmitted infections (STIs); pregnancy tests; tubal ligations for females aged 21 and older; and vasectomies for males aged 21 and older. Enrollment opened June 1, 2021, for Medicaid expansion which offered the full benefit package for women before, during and after pregnancy. OHCA worked to move individuals off SoonerPlan and onto SoonerChoice coverage. For FY2023, SoonerPlan only provided coverage to 555 individuals, accounting for only 0.59% of Medicaid enrollment while expansion provided coverage for 713,659 enrollees (up from 324,142) accounting for 28.47% of enrollees. During the process of “unwinding” after the public health emergency ended, OHCA identified a continued need for SoonerPlan as an option and work started to apply to the Centers for Medicare and Medicaid Services (CMS) for a SPA again to continue the SoonerPlan program. The proposed new SPA raises the income eligibility standard from 133% FPL to 205%, matching the eligibility level for extended postpartum coverage.
FP services continued to be provided through CHDs and contract clinics despite the loss of Title X funds. After a brief period of limited services, state funding was secured to replace the grant funds to continue funding the program at the same level. Services included medical histories; physical exams; laboratory services; methods education and counseling; provision of contraceptive methods; STI/human immunodeficiency virus (HIV) screening and prevention education; pregnancy testing; immunizations; and preconception health education. OSDH continued promoting the CDC/HHS guidelines for providing Quality Family Planning Services (QFP), requiring client-centered contraceptive counseling, and presenting information on the most effective methods of contraception first depending on the client’s desire to prevent or achieve pregnancy in the next year.
OHCA and OSDH continued the partnership through the Health Services Initiative, matching Children’s Health Insurance Program (CHIP) funds and state dollars to purchase LARCs for clients less than 19 years old, so that most clients could receive their method of choice on the date of service.
Through the collaborative Focus Forward Oklahoma Initiative, OHCA led efforts to recruit and train health care providers across the state on contraceptive counseling and LARC procedures. The Focus Forward Oklahoma (FFO) Program operated under three primary strategies for addressing barriers to access the most effective methods of contraception. These included: policy change, education, and communication. Since its inception, the program has removed restrictions on LARC devices for SoonerCare members from the Oklahoma State Plan for Medicaid, worked in partnership with OSDH to develop a Health Service Initiative through CHIP to increase the number of LARC devices available to uninsured women under 19, and created a LARC carve-out for federally qualified health centers (FQHCs), so that they can be reimbursed for LARCs outside of the prospective payment system. Efforts to best address inventory management for LARC are underway this year. Education efforts have focused on provider workforce development to increase the number of providers who provide LARCs to patients. Since 2017, 43 training sessions focused on best practices, “in-patient”-centered counseling and hands-on LARC procedure skills hosted at no cost to the trainees. A total of 547 providers from across the state have been trained in the curriculum. Sixty-five percent of providers were from the two major metropolitan areas of Oklahoma (Oklahoma City/Tulsa) and 35% were from rural areas in Oklahoma. Five provider types have attended the training sessions: 1) Physician MD, 33%; 2) Physician DO, 20%; 3) Physician Assistant, 8%; 4) Advanced Practice Registered Nurse/Certified Nurse Practitioner, 30%; and 5) Certified Nurse Midwife, 1%. Four specialties were represented at the training sessions: 1) Family Practice/Primary Care, 70%; 2) Obstetrics/Gynecology, 17%; 3) Pediatrics, 9%; 4) Other (e.g., Internal Medicine, Emergency Medicine), 5%. In 2019, clinical and administrative staff training sessions were added to the program to better support provision of the full range of contraceptive options. The program maintained a website to house information related to the program and resources for patients, providers, and community partners. FFO staff also continued to conduct outreach to the provider and patient community.
Challenges:
The biggest challenge this year was the loss of Title X funds. Since the notice of termination was retroactive, the agency had to immediately sequester all contraceptives and medications, find alternate funding for staff and supplies, and work with Apexys to figure out a method for maintaining 340B eligibility. This sudden change left frontline staff with little information when meeting clients face-to-face in the clinic until program staff and leadership could secure alternate funding and provide guidance for moving forward. An untoward consequence was the loss of the federal protection to provide confidential services to adolescents.
When the Supreme Court overturned Roe v. Wade with the decision in Dobbs v. Jackson, clinics saw an increase in the requests for LARCs. Private clinics and religiously affiliated hospitals and their clinics do not always offer this option based on cost and doctrinal beliefs. When OSDH clinics were forced to sequester all contraceptives, this limited the options available for clients to access LARCs in the more rural areas of the state.
Three additional major challenges continued to impede progress towards reaching this goal: education, religiously affiliated hospital systems, and access to providers in rural areas of the state.
Reaching and educating busy physicians and other health care providers remained a challenge this year. LARC trainings through the FFO program were still scheduled in Tulsa and Oklahoma City but expanded to rural areas too. Training was scheduled in several locations around the state, but some were cancelled due to low response rates and logistics.
Religiously affiliated hospital systems managed a large number of smaller hospitals and physician practices where LARCs could not be provided immediately postpartum in the hospital. Frequently, LARCs could not be provided during a physician office visit if the physician was associated with these hospital systems. Clients were referred to another provider if they chose a LARC method for contraception, erecting significant barriers especially in rural areas of the state. Oklahoma’s large rural population primarily relies upon local public health department clinics to provide publicly supported FP services. According to the Office of Primary Care, all but 4 of Oklahoma’s 77 counties were designated as health professional shortage areas due to either a low-income population or a shortage of primary care providers for the entire population of the service area. See the OSDH Map below for green areas indicating Medically Underserved Areas & Population.
Smaller hospitals, physician practices, and some FQHCs faced financial barriers in purchasing LARCs and having them available for same-day insertion. Some hospitals and providers were still unaware that LARCs could be placed immediately postpartum and billed separately from the global delivery charge.
Health Care Access Objective 1: Reduce the rate of unintended pregnancies (mistimed or unwanted) among mothers who have live births from 29.3% in 2016-2018 to 25.0% by 2025.
Data:
PRAMS data were used to monitor unintended pregnancy within Oklahoma. For 2021 births, 53.0% of mothers reported an intended pregnancy (a slight increase from previous reporting period at 52.3%), 30.0% reported an unintended pregnancy (previously 30.6%), and 19.1% (previously 17.0%) reported they were not sure what they wanted. This does not reflect significant changes from the previous reporting period.
Successes:
OHCA continued provision of FP services through SoonerPlan, the SPA. Medicaid expansion became effective July 1, 2021. See Objective 2 for more information on these programs.
OSDH continued to support eligibility staff in all county health departments trained to assist clients with the online enrollment process to help link clients with services (including contraception). Eligibility was determined (for any Medicaid program including Title XIX, SoonerPlan, SoonerChoice, or Insure Oklahoma) at the time of application, and clients were immediately provided with a Medicaid ID number to use in covering the cost of services for that day, as well as, setting up appointments if referrals were indicated. Enrollment opened June 1, 2021, for Medicaid expansion which offered the full benefit package for women before, during and after pregnancy. OHCA worked to move individuals off SoonerPlan, the limited benefit package, and onto SoonerChoice coverage, a full benefit package. For FY2023, SoonerPlan only provided coverage to 555 individuals, accounting for only 0.59% of Medicaid enrollment while expansion provided coverage for 713,659 enrollees (up from 324,142) accounting for 28.47% of enrollees. During the process of “unwinding” after the public health emergency ended, OHCA identified a continued need for SoonerPlan as an option and work started to apply to CMS for an SPA again to continue the SoonerPlan program. The proposed new SPA raises the income eligibility standard from 133% FPL to 205%, matching the eligibility level for extended postpartum coverage.
FP services continued to be provided through CHDs and contract clinics despite the loss of Title X funds. Services included: medical histories; physical exams; laboratory services; methods education and counseling; provision of contraceptive methods; STI/HIV screening and prevention education; pregnancy testing; immunizations; and preconception health education. All FP clients seen for an initial or annual exam were asked if they intend to be (i) pregnant within one year, (ii) greater than one year from the visit, or (iii) never. Contraceptive counseling was then focused on the options to best meet their reproductive plans.
See Objective 2 for a discussion about LARC activities, supplemental funding, and professional training opportunities.
Staff employed in MCH administered the federal Title V, Personal Responsibility and Education Program (PREP) funds, and the Title X grant through April. The FP program continued providing the full scope of services through funding secured through the Oklahoma Legislature. Many activities between these programs overlapped to prevent unintended pregnancies.
Staff development opportunities were scheduled throughout the year based on the MCH annual staff development training needs assessment, as well as Federal Title V and Title X FP priorities and key issues. However, with the loss of Title X requirements for training, training was limited to the following topics: child abuse and neglect reporting, human trafficking, intimate partner violence; navigating behavioral and mental health post pandemic for youth and adolescent; men’s health and male involvement in reproductive health; and maternal and infant health updates.
CHDs continued to assess preconception health with the 24,862 female clients in the clinic for preventive health check-ups and pregnancy tests.
The Perinatal and Reproductive Health Division (PRHD) maintained a web page under the Preparing for a Lifetime Initiative page on preconception health entitled “Before and Between Pregnancy” with information on living a healthy lifestyle, making healthy food choices, getting regular health check-ups, emotional wellness and support, knowing health and pregnancy risks, and provided a list of free resources.
A PSA entitled “Measure Up” was available on the OSDH website for use on television and radio. The PSA promoted the importance of being healthy prior to pregnancy and planning for pregnancy.
Through the contract with Cox Media, MCH ran creative ads on streaming services with messages regarding preconception health and healthy pregnancies like the examples below. The previously created public service announcements, Measure Up (preconception health) and Caring Dads (secondhand smoke and newborns) were also run on the streaming services.
MCH also utilized the Cox contract to run social media messages like the below Post-Birth Warning Signs and promotion of the OSDH maternity clinics.
Challenges:
The biggest challenge was the sudden loss of Title X funds in April which essentially halted most FP visits until new protocols, procedures and funding sources could be identified. Visits were prioritized and rescheduled, when possible, for a few months. Contraceptives were only available through prescriptions as the loss of 340B eligibility was navigated. Fortunately, through collaborations between agency divisions and partners, other options were identified within 30 days. Contraceptive options were limited for a while but there was never a break in service delivery. However, losing the ability to provide confidential services to adolescents created a bigger barrier that will have long lasting effects.
The long-standing challenge remained in relation to changing the paradigm for men and women of reproductive age to value preventive health visits more than intervention (sick) visits and to understand the importance of creating a reproductive life plan to help them meet personal and professional goals.
The lack of standard health education curriculum in schools across the state continued to leave many adolescents without access to accurate health and sexual health related information. In addition, the climate for teen pregnancy prevention programming in schools became increasingly more difficult.
Access to care continued to be an issue, especially in the rural areas. Based on the March of Dimes 2024 Maternity Care Desert Report, in 2021 53.2% of the 77 counties in Oklahoma were maternity care deserts, and 19.5% of counties had low or moderate access, but not full access This designation was determined by the number of hospitals offering maternity care, the number of OB/GYN and Certified Nurse Midwife (CNM) providers per 100,000 population, and the proportion of women 16-64 without health insurance. A lack of these health care providers erected significant barriers in access from contraception to prevention of unintended pregnancies. Only 27 out of 77 counties had a hospital capable of delivering infants. According to OPQI, these conditions remained in 2022 as there were only 43 delivering hospitals in the state.
Oklahoma’s large rural population primarily relied upon local public health department clinics to provide publicly supported FP services with 66 of Oklahoma’s 77 counties designated as health professional shortage areas. FQHCs also provided services in most areas of the state, however, there was very limited access to FQHCs in the southwest area of the state. Due to the negotiated reimbursement rate for LARCs in the state, many of these sites either did not offer LARCs or offered a limited number. Although effective at preventing unintended pregnancies, the upfront cost of LARC methods continued to be prohibitive for some health care providers.
SPM 1: Maternal Mortality rate per 100,000 live births
Objective 1: Reduce maternal mortality rate from 28.8 maternal deaths per 100,000 live births in 2016-2018 to 23.8 by 2025.
Data:
Maternal death continued to be the international standard by which a nation’s commitment to women’s status and their health could be evaluated. The Maternal Mortality Rate (maternal deaths within 42 days of termination of pregnancy per 100,000 live births) for Oklahoma from 2019-2021 among women aged 10-44 years substantially increased from 25.2 in the previous reporting period (2018-2020) to 31.0 deaths per 100,000 live births. Despite national and local efforts to address maternal morbidity and mortality, disparities still exist in relation to race, age, and education level. For confidentiality reasons, MCH policy for reporting Oklahoma maternal mortality rates required that only three-year rolling averages could be released.
Successes:
MCH continued to provide leadership for the Maternal Mortality Review Committee (MMRC). Oversight was provided by the Perinatal and Reproductive Health Division Administrative Program Manager (APM) and one of the Advanced Practice Nurses who continued in the project manager role. With the passage of House Bill (HB) 2334, the MMRC became a statutory committee with expanded access to additional records vital for accurate case review. The MMRC remained an essential community process used to enhance and improve services to women, infants, and their families. Qualitative, in-depth reviews investigated the causes and circumstances surrounding each maternal death. Through communication and collaboration, the MMRC served as a continuous quality improvement system that resulted in a better understanding of maternal issues. The overall goal of the MMRC was prevention through understanding of causes and risk factors. The list of maternal deaths, obtained from the Vital Records Division, was reviewed by the APM and the PRH Medical Director to determine which cases would be reviewed by the committee. All possible pregnancy-related and pregnancy-associated deaths were reviewed for women who died while they were pregnant or within 365 days of the end of the pregnancy. Two nurse practitioners and the nurse manager abstracted cases for review. HB2334 defined the make-up of the committee with 18 permanent positions representing various organizations and disciplines, as well as seven community positions appointed by the Oklahoma Commissioner of Health. The MMRC reviewed two to eight cases at quarterly meetings from October 2022 through September 2023 to identify gaps in services or possible system level changes to prevent future maternal deaths. The top causes of death were hemorrhage and infection. Half of the deaths due to hemorrhage were caused by a ruptured ectopic pregnancy, and a quarter were caused by postpartum hemorrhage. Among deaths due to infection, 42.9% were caused by sepsis and 28.6% were caused by COVID-19.
The Maternal Mortality Review Information Application (MMRIA) database continued to be used to collect and report data. Cases were abstracted directly into this database and reviewed prior to the meetings. Committee members came prepared to discuss the cases which allowed the completion of more cases during each meeting.
The Council on Patient Safety in Women’s Health Care continued to provide leadership for the program “Alliance for Innovation on Maternal Health (AIM): Improving Maternal Health and Safety”. Oklahoma was the first AIM state, based on infrastructure and activities put in place through the ‘Every Mother Counts Initiative’ in 2014. The OPQI continued to provide leadership for these efforts providing technical assistance for participating hospitals on data entry, policy development, and emergency drills. The participating Oklahoma birthing hospitals worked on postpartum hemorrhage and/or hypertension initially. Those measures transitioned to nationally reported measures, so OPQI continued to provide support for reporting those measures but began focusing more on reporting on the bundle addressing opioid use disorder. The Oklahoma Mothers and Newborns Affected by Opioids (OMNO) initiative provided data and technical support for this initiative. Information on outcome measures was entered into the database through the Vital Records Division. Process measure information was entered by individual hospital staff. Hospitals meeting certain criteria are usually recognized as “Spotlight Hospitals” annually during the OPQIC summit for participating in this initiative and other quality improvement initiatives. Awards returned this year at the Summit. The TeamBirth model of service delivery was adopted in some form in every birthing hospital in the state. This model ensures the patient has an active voice in her plan of care and that she is included in the decision-making process.
The Oklahoma Maternal Health Task Force (OMHTF), created in connection with the State Maternal Health Innovation Grant, continued to work toward the objectives of the strategic profile for 2020-2024 which defined maternal health and established work groups for the four priority pillars: (i) Improve Access to Appropriate Care and Maternal Health Programs; (ii) Expand Mental Health, Substance Use and Social Services; (iii) Implement Innovative Technology and Data Systems; and (iv) Address Racial Disparities. This year, the work groups focused on activities within each domain including: promoting telehealth recommendations for prenatal care; supporting OHCA efforts to expand postpartum coverage to 12 months and provide coverage for doulas; established a database for maternal health data; working with the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) on interventions to support mothers with substance use disorders; offering training on health equity and implicit bias for health care providers statewide; and assessing resources for expanding access to midwifery and doula care.
The annual Oklahoma Maternal Health, Morbidity, and Mortality Report was released in September 2023. This report included definitions for mortality and morbidity, top causes of death and socioeconomic and health-related contributing factors, an overview of women’s health in Oklahoma, data from the MMRC case reviews, and recommendations from the MMRC to improve maternal health and help prevent future maternal deaths. This report can be found at: https://oklahoma.gov/content/dam/ok/en/health/health2/aem-documents/family-health/maternal-and-child-health/maternal-health-task-force/MMRCAnnualReport2023PRINT1.pdf
Challenges:
Competing priorities and travel distance still provided some challenges for MMRC member attendance, however the committee was able to meet quorum for all meetings this year.
One of the greatest challenges was developing recommendations that addressed the social determinants of health. Committee members found it much easier to develop “clinical” recommendations that target hospitals and providers, which was only one piece of the puzzle for reducing maternal mortality. Identifying actionable recommendations posed a significant challenge.
The impact of COVID-19 on maternal deaths continued to be discussed as the committee reviewed deaths involving a positive COVID-19 diagnosis during pregnancy or the immediate postpartum period. Discussions proved that there were significant differences in how healthcare providers viewed the impact of COVID-19 and whether it was the cause of death or a contributing factor for the cases reviewed.
Continued challenges related to preconception health and pregnancy intention were identified as contributing factors for many maternal deaths. Common themes among contributing factors at the patient or family level included delays in seeking and receiving care, adherence to recommendations, substance use disorders, and chronic conditions (e.g., obesity, tobacco use). Delays in seeking care were attributed to lack of access or financial resources, stigma, cultural or religious factors, and knowledge of when to seek care. Lack of adherence to recommendations at the patient level were noted, such as lack of or limited prenatal care and being unvaccinated for COVID-19 and influenza, specifically for deaths caused by infections.
OSDH, ACOG, the OHA, and other partners worked together again to support legislation requiring all maternal deaths be reported to the Medical Examiner’s Office. The bill introduced in the legislature during the last legislative session did not advance past the legislative committee level. To gain support from legislators, partners must agree to reduce the statutory size of the committee.
NPM 1: Percent of women, ages 18 through 44, with a preventive medical visit in the past year.
Objective 1: Increase the percent of county health department sites appropriately utilizing the PHQ-9 tool for screening and the new codes for positive and negative screening from 61 sites in February 2020 to 90 sites by 2025.
Health Equity Objective 1: Create culturally competent public service announcements (PSAs) and messages on maternal mental health that are representative of African American, Native, and Latinx women and men impacted by Perinatal Mood and Anxiety Disorders (PMADs) by 2025.
Data:
According to 2018-2022 data from TOTS, 59.9% of new mothers were screened for postpartum depression. Eighteen percent of mothers with toddlers indicated they had been diagnosed with postpartum depression (PPD) sometime after their toddler was born.
Successes:
The Maternal Mood Disorders workgroup continued to meet and engage with community members, family advocates, mental health professionals, and public health professionals to work towards the goals of reducing stigma, increasing capacity of available resources for parents in need of perinatal mental health support, and increasing education on Perinatal Mood and Anxiety Disorders (PMADs). In service of these goals, one of the initiatives discussed to be piloted in Carter County Health Department is the implementation of the Reach Out, Stay Strong, Essentials (ROSE) psychoeducational curriculum with new mothers. Developed by clinical psychologist Dr. Jennifer Johnson of Michigan State University College of Human Medicine, and Dr. Caron Zlotnick of Brown University, Butler Hospital, and Women and Infants Hospital, this program is evidence-based and has been shown to reduce cases of postpartum depression by half among low-income women in a series of randomized trials. Its primary focus is to assist new mothers in recognizing the changes in role they will make from single person to mother, the change in their identity (what is lost in this transition and what is gained), and to help them recognize, identify, and bolster their support systems so they are best prepared for their postpartum period after they give birth. The goal is to implement the program as a pilot in Carter County Health Department due to this location having a maternity clinic and social worker available to implement the program with a readily available population.
The co-lead for the Oklahoma Maternal Mood Disorders workgroup conducted an educational session at a community baby shower held by the Citizen Pottawatomi Nation, conducting eight educational sessions on the symptoms, prevalence, treatment, and resources for PMADS. There were many families at the event, with a total count of 1000 participants.
When the Policy Center for Maternal Mental Health released their Maternal Mental Health State Report Cards in May of 2023, there were several disparities in their reporting for Oklahoma based on their measured metrics. They did not include the statewide workgroup, state statute on the postpartum depression screening, or the statewide directory of available mental health professionals trained in perinatal mental health. The Policy Center received this information and changed their initial grade for Oklahoma of an “F” to a grade of “D+”, which moves Oklahoma in their scoring metrics from the bottom to the median grade available (the scale is “F” at the lowest to “B- “at the highest).
In a further effort to increase the resources available to parents impacted by PMADS, planning for another Postpartum Support International (PSI) Perinatal Mental Health Certification training was underway during the months prior to the end of the grant period. The focus of those recruited to attend and obtain the training and certification continued to be mental health professionals who work with parents in the perinatal period, and who primarily work in rural areas where the need is greatest. There were another 45 mental health professionals who expressed interest in attending the training and completing the certification.
Challenges:
Local champion and PSI Climb Out of the Darkness leader Emily Clark stepped down from her role, with no new replacement. This left a vacuum in the leadership of the event, but there were several individuals who may be able to step in from the existing committee.
The effort to locate appropriate participants for the culturally competent PSAs continued to be a struggle. The Maternal Mood Disorders Workgroup lead has continued to connect with partner agencies, hospitals, mental health agencies, OBGYN and pediatric clinics to locate suitable candidates to share their story. However, to date there have not been other individuals willing and able to tell their story about perinatal mental health on video.
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