NPM: Percentage of women with a past year preventive medical visit

 

Objective 1. Increase the number of women returning for the postpartum visit from 88.0% in 2012-2014 to 95.0% in 2020.

 

Data:

According to the most recent Pregnancy Risk Assessment Monitoring System (PRAMS) data (2016-2018), 87.3% of new mothers in Oklahoma attended their postpartum visit with the postpartum visit rate increasing from 86.5% in 2016-2017. Mothers who reported their pregnancy was intended had a higher postpartum visit rate (52.9%) than mothers who reported their pregnancies were unintended (29.3%) or they were not sure (17.8%). With global billing and reimbursement for obstetric services, claims data were not available to support this self-reported percentage. As in previous years, 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.

 

Successes:

PRAMS data were used to update fact sheets on American Indian mothers, African American mothers and unpaid maternity leave. According to 2016-2017 data, 76.6% of African American women reported using some form of postpartum birth control compared to 81.1% of American Indian mothers and 80.7% of mothers from other races. The percentage of African American mothers with Medicaid was significantly higher at 76.2% than American Indian at 62.3% and mothers from all races at 57.5%. 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. Sixty-seven percent of Oklahoma mothers worked during their most recent pregnancy with 56% returning to work at the time of the survey. The majority of working mothers (61%) used unpaid leave time to stay at home and consequently could not stay home for as long as they desired.  This may have affected the ability of these mothers to take additional time off to attend a postpartum visit.

 

County health department 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 county health department 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.

 

Within OSDH, the Family Support and Prevention Service provided oversight for all of the home visiting programs under the parentPro umbrella. parentPro remained a resource that connected parents and caregivers with free, voluntary family support in their community in the comfort of their own home. Pregnant women and parents with children birth to kindergarten, could enroll in the program best suited to meet their needs. MCH staff assisted in training the parentPro staff on medical norms for the pregnancy and postpartum periods. In the Parents as Teachers (PAT) program, the parent educator first ensured that the family had a medical home (whether the mother was pregnant or postpartum). This included a primary care provider (PCP) for the mother and baby. In addition, the parent educator helped mothers to understand the importance of maternal health, what to expect during a postpartum visit, and questions she may want to ask her health care provider. The parent educator supported the mother by helping her make timely postpartum appointments and provided transportation, if needed.

 

The PAT curriculum contained lessons that addressed the postpartum period called “Normal Postpartum Adjustment”. In addition, the parent educator had access to handouts that addressed adjusting to the birth of the baby and signs and symptoms of postpartum depression. Parent educators performed the Patient Health Questionnaire (PHQ9) to screen for postpartum depression which was administered by the 4th home visit or if the mother was pregnant, in her 36th week. It was administered again when the infant was between 4-6 months, and then annually. Also, it could be administered at any time if the parent educator suspected depression.

 

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 addressed life course development (including Personal Health, Environment, Family and Friends, and Maternal Role) with the client in the prenatal period. 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 are scheduled weekly during the first 4 visits and during the first six weeks postpartum. Mothers were also asked, up to 12 weeks postpartum, if they had returned for a postpartum visit. These questions provided a natural segue way to encourage the client to attend the postpartum exam.

 

In October 2017, the University of North Carolina received new funding to reduce infant mortality and improve birth outcomes by advancing the status of women's preconception health particularly for low-income women and women of color in some of the country's most underserved communities. Oklahoma was chosen to participate in this grant opportunity based on work with previous Collaborative Improvement and Innovation Network (CoIIN) teams focused on preconception health. MCH recruited seven partners for this team: two family planning clinics, all four Healthy Start Projects in the state, and a Federally Qualified Health Center (FQHC). The FQHC dropped out of the project this year but the remaining six sites remained engaged. The goal for this Preconception CoIIN team was to develop, implement, and disseminate a woman-centered, clinician-engaged, community-involved approach to the well woman visit to improve the preconception health status of women of reproductive age, particularly low-income women and women of color. A new preconception/Interconception screening tool was developed through the Human Centered design process. All sites have incorporated the tool into their protocol. Family planning clinics used the tool with clients scheduled for an initial or annual women’s health visit. Two of the Healthy Start projects involved in this team worked on developing guidelines for staff to use the tool to prepare clients for their postpartum or well-woman visit. The tool is now available in five languages: English, Spanish, Burmese, Marshallese, and Zomi.

 

Challenges:

The Oklahoma State Department of Health, in conjunction with partners at the Oklahoma Health Care Authority (OHCA, the State’s Medicaid agency) and private insurers, have been unsuccessful in attempts to change the rate methodology for reimbursement for obstetrical services, splitting out the postpartum visit 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.

 

Oklahoma remained a state without Medicaid expansion. The limited benefit package for some Medicaid recipients (Soon-to-be-Sooners), did not cover the postpartum visit limiting the ability of some mothers to even schedule a 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. The large percentage of working mothers without paid leave forced new mothers to return to work early, making it difficult to attend postpartum and newborn health care visits.

 

Internal challenges interfered with the ability of MCH staff to send out postpartum postcard reminders for most of the year. New postcards have been printed and mailing will resume again soon.

 

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 12.0% in 2014 to 15.5% in 2020.

 

Data: 

Baseline data (state fiscal year (SFY) 2014) indicated 8.5% of females < 18 year olds, 16.3% of 19-24 year olds, and 14.7% of females > 25 with Medicaid-funded health care relied on long acting reversible contraception (LARC) methods. Calendar year (CY) 2018 data show 3% of females under 15, 6% of females < 19 years old, 14% 20-24 year olds, 15% of 25-29 year olds, 14% of 30-34 year olds, 12% of 35-39 year olds, 10% of 40-44 and 7% of females 45 years or older with SoonerCare relied on a LARC method. This provided an overall LARC utilization rate of 15.0% for SoonerCare members in CY 2018.

 

Successes:

The Oklahoma Health Care Authority (OHCA) continued provision of family planning services through SoonerPlan, the state plan amendment (SPA). 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 family planning, birth control information, methods, and supplies; laboratory tests including pap smears and screening for sexually transmitted diseases (STDs); pregnancy tests; tubal ligations for females age 21 and older; and, vasectomies for males age 21 and older.

 

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, 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. As of September 30, 2019, SoonerPlan provided coverage to 28,444 enrollees accounting for 3.60% of Medicaid enrollment.

 

Family planning services were provided through county health departments and contract clinics. Services included medical histories; physical exams; laboratory services; methods education and counseling; provision of contraceptive methods; STD/human immunodeficiency virus (HIV) screening and prevention education; pregnancy testing; immunizations; and preconception health education. OSDH continued promoting the guidelines for the provision of family planning services released in April 2014 (updated in 2016), providing Quality Family Planning Services (QFP), requiring contraceptive counseling to present information on the most effective methods of contraception first. The Family Planning Annual Report (FPAR) for calendar year 2019 indicated 5.4% of clients relied on intrauterine devices/systems and 8.2% of clients relied on the implant for contraception. This equates to 13.6% of all users and 20.6% of clients choosing a hormonal method of contraception relying on a LARC method. Family planning services were provided to a total of 35,958 females and males of reproductive age for calendar year 2019. Of the 35,958 clients, 6,275 relied on public insurance and 24,072 were considered uninsured (SoonerPlan clients were included in the uninsured category for the purposes of FPAR since benefits are limited to only family planning related services).

 

Historically, only Title X funds were utilized to purchase LARCs for the OSDH clinics. With additional funding from the Prevent Block Grant and Medicaid CHIP (Children’s Health Insurance Program) to purchase LARCs, waiting lists were virtually eliminated creating availability for most clients on their date of service. Prevent Block Funding ended this year as a resource for LARCs. An MOU was established this year with a Federally Qualified Health Center in Stigler, Oklahoma allowing OSDH to share up to 50 Nexplanon purchased with Prevent Block funds increasing access to LARCs for this high poverty, rural area.

 

Through the collaborative Focus Forward Oklahoma Initiative, the OHCA led efforts to recruit and train health care providers across the state on counseling and insertion for LARCs. The Focus Forward Oklahoma (FFO) Program had three primary strategies for addressing barriers to access of 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, and more recently focused policy efforts on explorations of access at health departments and Federally Qualified Health Centers (FQHCs). In particular, in partnership with OSDH, the program was able to get a Health Service Initiative through the Children’s Health Insurance Program approved to increase the number of LARC devices available to uninsured women under 19. Education efforts have focused on provider workforce development to increase the number of providers who provide LARCs to patients. Since 2017, 23 training sessions focused on best practices in patient-centered counseling and hands-on LARC procedure skills have been hosted at no cost to the trainees.

 

A total of 234 providers from across the state have been trained in the FFO curriculum. Sixty-six percent of providers were from the two major metropolitan areas of Oklahoma (Oklahoma City/Tulsa) and 34% were from rural areas in Oklahoma. Five provider types have attended the training sessions: 1) Physician MD, 44%; 2) Physician DO, 11%; 3) Physician Assistant, 11%; 4) Advanced Practice Registered Nurse/Certified Nurse Practitioner, 32%; 5) Certified Nurse Midwife (CNM), 2%. Four specialties were represented at the training sessions: 1) Family Practice/Primary Care, 74%; 2) Obstetrics/Gynecology (OB/GYN), 12%; 3) Pediatrics, 10%; 4) Other (e.g. Internal Medicine, Emergency Medicine), 4%. 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 has a website that houses 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:

Three 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. The OSDH, Oklahoma Health Care Authority and Oklahoma Perinatal Quality Improvement Collaborative have all attempted to educate health care providers and promote LARCs – especially, postpartum LARC insertion. However, many providers were still hesitant to counsel on and insert the most effective methods, especially immediate postpartum LARCs. LARC trainings were all provided in Oklahoma City and Tulsa. No training was provided for clinicians in the western half of the state. This was due to financial resources, availability of trainers, and access to simulators for training.

 

Although the OHCA started covering the placement of LARCs prior to hospital discharge after delivery effective September 1, 2014, utilization of this benefit remained low.

 

Religiously affiliated hospital systems managed a large number of smaller hospitals and physician practices and LARCs could not be provided immediately postpartum in those hospitals. Frequently, they could not be provided in the physician offices either for physicians associated with those hospital systems. Clients were referred to another provider when 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 family planning services. According to the 2015 Oklahoma Health Work Force Data Book, 66 of Oklahoma’s 77 counties were designated as health professional shortage areas.

 

Smaller hospitals, physician practices, and some Federally Qualified Health Centers 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.

 

Objective 3: Reduce the rate of unintended pregnancies (mistimed or unwanted) among mothers who have live births from 33.5% in 2014 to 31.8% by 2020.

 

Data:

PRAMS data were used to monitor unintended pregnancy within Oklahoma. For 2016-2018 births, 52.9% of mothers reported an intended pregnancy (a slight increase from previous reporting periods at 51.7% and 49.7%), 29.3% reported an unintended pregnancy (previously 30.0% and 33.5%), and 17.8% (previously 18.3%) reported they were not sure what they wanted. Positive trends were noted in the continued increase in intended births and decrease in unintended births.

 

Successes: 

OHCA continued provision of family planning services through SoonerPlan, the state plan amendment (SPA). See Objective 2 for more information on this program.

 

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, 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. As of September 30, 2019, SoonerPlan provided coverage to 28,444 enrollees accounting for 3.60% of Medicaid enrollment.

 

Family planning services were provided through county health departments and contract clinics. Services included medical histories; physical exams; laboratory services; methods education and counseling; provision of contraceptive methods; STD/human immunodeficiency virus (HIV) screening and prevention education; pregnancy testing; immunizations; and preconception health education. All family planning clients seen for an initial or annual exam were asked if they intend to be pregnant within one year, greater than one year from the visit or never. Contraceptive counseling was then focused on the options to best meet their reproductive plans.

 

See Objective 1 for information on the Preconception CoIIN project.

 

See Objective 2 for a discussion about LARC activities, supplemental funding and professional training opportunities.

 

Staff employed in MCH administered both the Title V and Title X federal programs and the PREP funds. Many activities between these programs overlapped to prevent unintended pregnancies.

 

MCH continued to receive funding through the federal Personal Responsibility Education Program (PREP) grant to maintain teen pregnancy prevention efforts. PREP funds continued to support projects in the Oklahoma City County Health Department (OCCHD) and Tulsa Health Department (THD). Both projects continued to build connections with schools and expanded their reach in providing evidence-based curricula: "Making a Difference!", "Making Proud Choices!”, “Love Notes”, “Reducing the Risk.”, and “Power through Choices” to assist in reaching out-of-home youth.

 

Staff development opportunities were provided throughout the year based on the MCH annual staff development training needs assessment as well as federal Title V and Title X Family Planning priorities and key issues. These trainings included anticipatory guidance and family participation for adolescents seeking family planning services; intimate partner violence and sexual coercion; human trafficking; infections and reproductive health; teen pregnancy prevention and adolescent mental health; preconception/interconception health (preconception health indicators, health screening, prevention of birth defects); adolescent health issues (adolescent sexual behaviors, school health, new Oklahoma consent law); and, medical marijuana.

 

Challenges:

The biggest challenge remained 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.

 

Access to care continued to be an issue especially in the rural areas. Based on data from the March of Dimes 2018 report on maternity care deserts, only 14 of Oklahoma’s 77 counties had access to maternity care. An additional 22 counties had limited access, however, the remaining 41 counties met the designation of a maternity care desert. This designation was determined by the number of hospitals offering maternity care, the number of OB/GYN and 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 to contraception to prevent unintended pregnancies. As of November 2018, only 27 counties had a hospital capable of delivering infants.

 

Oklahoma’s large rural population primarily relied upon local public health department clinics to provide publicly supported family planning services with 66 of Oklahoma’s 77 counties designated as health professional shortage areas. Federally Qualified Health Centers (FQHC) 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 long acting reversible contraception (LARC) in the state, many of these sites either do not offer LARCs or offer a limited number. Although effective at preventing unintended pregnancies, the upfront cost of LARC methods continued to be prohibitive for some health care providers. The Focus Forward Program continued to work towards making the methods more accessible through additional providers across the state.

 

Objective 4: Create a Communication and Dissemination Plan to educate reproductive age males and females on being healthy before and between pregnancies in areas of the state with the highest infant and maternal mortality rates by December 2017.

 

Data:

The number of service sites utilizing the Women’s Health Assessment Tool developed by the Oklahoma State Department of Health (OSDH) or any alternative tool remained constant this year. Every county health department utilized the Women’s Health Assessment with clients being seen for an initial or annual exam and all clients with a negative pregnancy test desiring pregnancy.

 

Successes:

County health departments continued to utilize the Women’s Health Assessment tool with more than 35,670 female clients in the clinic for preventive health check-ups and pregnancy tests.

 

See Objective 1 for information about the UNC-led Preconception CoIIN work on the new patient engagement tool.

 

MCH staff shared preconception health and prematurity information at the annual March of Dimes Walk for Babies on May 4, 2019 including Prescription for a Healthy Future for men and women, folic acid, progesterone therapy for prevention of subsequent preterm births, and tobacco cessation.

 

Information shared via social media posts during Women’s Health Week focused on breast and cervical cancer, preconception health, maternal mood disorders, congenital syphilis, and smoking during pregnancy. Information for Men’s Health Week focused on getting regular check-ups, prevention of unintentional drug overdoses and help for substance abuse, prostate cancer screening, father’s role in the social and emotional development of their children, tobacco use prevention, and depression in men. Press releases focused on recommended screenings and the importance of being healthy for both men and women. Information was also posted on the importance of immunizations prior to pregnancy and during pregnancy (flu and Tdap).

 

The Perinatal and Reproductive Health Division (PRHD) also 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 public service announcement (PSA) entitled “Measure Up” was available on the website for use on television and radio. The PSA promoted the importance of being healthy prior to pregnancy and planning for pregnancy. The PSAs on preconception health and smoking and pregnancy also aired on television stations statewide in May for Women’s Health Week and in June, the preconception and second hand smoke from dads PSAs aired for Men’s Health Month.

 

Challenges:

A billing code was established to help track usage of the Women’s Health Assessment, however, during Comprehensive Program Review visits, chart audits continued to indicate that the code was not consistently used. County staff was educated but data accuracy has continued to be a challenge and, consequently, data do not reflect actual usage.

 

Changing the paradigm from reactive to proactive with emphasis on establishing a reproductive health plan and taking steps to ensure reproductive goals are reached resulting in healthy, intended pregnancies remained a challenge. Health care providers were busy and often did not have time for counseling and planning. A multitude of resources were available to assist with preconception health counseling; however, busy providers did not have time to review and assess all the resources available in order to choose a resource that would work best for each of them. County health department clients have seen the same Women’s Health Assessment tool for many years now and consequently are not as engaged in the assessment and education. The sites piloting the new CoIIN tool did experience significantly more buy-in and discussion regarding health behaviors and risks.

 

Changing electronic health records to include a preconception health assessment was frequently too time consuming and costly, presenting a barrier for some sites. Federal funding requirements for some programs include lengthy data collection tools, including preconception health questions, leaving little time for education.

 

SPM 2 Maternal mortality rate per 100,000 live births

 

Objective 5: Reduce maternal mortality rate from 19.4 maternal deaths per 100,000 live births in 2013-2015 to 17.5 by 2020.

 

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 2016-2018 among women aged 10-59 years was 24.9 maternal deaths per 100,000 live births (up from 23.8 for 2015-2017). The goal of Healthy People 2020 was to reduce the Maternal Mortality rate to no more than 11.4 per 100,000 live births. This measure was based on a three-year rate of those deaths occurring within forty-two days from termination of pregnancy to assure the availability of comparable data to other state and national rates. 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. Oversight was provided by the Perinatal and Reproductive Health Division (PRHD) Administrative Program Manager (APM) and one of the Advanced Practice Nurses transitioned into the project manager role. With the passage of HB 2334, the Maternal Mortality Review Committee became a statutory committee with expanded access to additional records vital for accurate case review. The Maternal Mortality Review Committee (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 the maternal issues. The overall goal of the MMR 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. The APM, three nurse practitioners, and the nurse manager abstracted cases for review. In Oklahoma, the committee had been broadly representative of medical, social and community services, and providers. 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 Commissioner of Health. The committee reviewed three to four cases at quarterly meetings to identify gaps in services or possible system level changes to prevent future maternal deaths. The top causes of death were cardiovascular, sepsis, non-cardiovascular, and hemorrhage.

 

MCH continued to work with the CDC on options for transitioning to the network-based Maternal Mortality Review Information Application (MMRIA) database to help states collect and report comparable data. Technical and funding issues prevented the transition from occurring this year. Central hosting became a viable option for accessing MMRIA and planning began to switch to this database in the spring.

 

The Council on Patient Safety in Women’s Health Care was re-awarded a four-year, $4 million cooperative agreement from the Health Resources and Services Administration (HSRA) Maternal and Child Health Program in 2018. The national goal is to prevent 100,000 severe complications during delivery hospitalizations and 1,000 maternal deaths over the course of the funding period. The agreement funds the program “Alliance for Innovation on Maternal Health (AIM): Improving Maternal Health and Safety”. AIM collaborated with public, private, and professional organizations to focus on the areas of obstetric hemorrhage, severe hypertension, venous thromboembolism, reduction of primary cesarean births, and reduction of racial disparities during pregnancy contributing to maternal morbidity and mortality. Oklahoma was the first AIM state based on infrastructure and activities put in place through the Every Mother Counts Initiative in 2014. The Office of Perinatal Quality Improvement (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. Information on outcome measures was entered into the database through the Vital Records Division. Process measure information was entered by individual hospital staff. Hospitals were recognized as “Spotlight Hospitals” for establishing protocols and entering data into the AIM data portal, in addition to meeting other criteria. The selected hospitals were celebrated during the Oklahoma Perinatal Quality Improvement Collaborative and Preparing for a Lifetime Summit held September 20, 2019. During the summit, the tool kit for the Obstetric Care for Women with Opioid Use Disorder bundle was presented to hospital staff to kick-off work on this bundle.

 

Challenges:

Although Oklahoma’s maternal mortality rate was high, the relatively small number of cases each year made it challenging to identify system level interventions to improve morbidity and prevent mortality.

 

Transition to the new MMRIA database did not occur based on the cost of hosting the database and logistics of putting an MOU in place between the agency and CDC.

 

Frequently, case review summaries were missing critical information. Prior to July 2019, there was no legislative support for MMR activities that required entities to provide information, causing incomplete case reviews and making system level changes difficult to identify. The new MMR legislation that went into effect in July will positively impact case abstraction and change committee structure for the November meeting.

 

Continued challenges related to preconception health and pregnancy intention were identified as contributing factors for many maternal deaths. To date, the MMRC has reviewed 126 cases with at least one of the following contributing factors listed for the majority of cases reviewed: obesity (BMI listed as high as 53.5), chronic hypertension, diabetes (not gestational diabetes), cardiac problems, and asthma/pulmonary issues.

 

Objective 6: Increase the percent of new mothers screened for postpartum depression at county health departments and partner agencies, from 44.5% in 2015 to 46.7% in 2020.

 

Data:

According to data from the 2015-2017 The Oklahoma Toddler Survey (TOTS), 48.7% of new mothers were screened for postpartum depression, exceeding the 2020 goal. Almost 14.3% of mothers with toddlers indicated they had been diagnosed with postpartum depression (PPD) sometime after their toddler was born.

 

Successes:

MCH continued to support efforts in outreach and screening with the county health department clinics throughout the state, and with partners in the Tulsa and Oklahoma City County Health Departments. These clinics continued to utilize the Edinburgh postnatal depression scale in most county health department clinics, with some of the clinics utilizing the PHQ-9 Patient Health Questionnaire. Across the county and City-County clinic system, there were 2,184 screenings conducted between October 1 2018-September 30, 2019.

 

One of the greatest successes this year in the education of and screening for Perinatal Mood and Anxiety Disorders (PMADs) in Oklahoma was the passage of Senate Bill 419. The legislation required all hospitals with labor and delivery services to provide new mothers, and fathers and other family members when possible, information about perinatal mental health disorders. This information, according to the bill, must include symptoms, coping methods, and available treatment resources. The bill also had impacts for OB/GYNs and pediatricians. The statute stated that OB/GYNs will be required to offer pregnant patients screening for PPD at least once during prenatal and postnatal visits. Pediatricians were also required to offer the mother screening for PPD at any well-baby checkup prior to the infant’s first birthday. Following the current American Academy of Pediatrics (AAP) recommendations for well-child visits at one, two, four, and six months of age, this could result in four opportunities for screening and referral for treatment. This bill was passed into law and signed by the Governor in April of 2019; effective November 1, 2019.

 

Stigma reduction, awareness, and education continued to be a focus of the Maternal Mood Disorders Work Group members. There were several community events where members conducted education regarding PMADs with new and pregnant families. One of these events was the inaugural community baby shower held by the Citizen Pottawattamie Nation, and another was a very large community baby shower held by the Oklahoma City-County Health Department (OCCHD), funded in part by grant funds from MCH. The community baby shower held by the OCCHD had over 1200 participants.

 

The first public service announcement (PSA) video produced by MCH in conjunction with the Communications Department at OSDH on postpartum depression and anxiety was filmed and released on May 10th, 2019. The reception to this video was overwhelmingly positive, and the press release announcing the video was picked up by several local newspapers.

 

The Preparing for a Lifetime Maternal Mood Disorders Work Group helped facilitate the formation of chapter officers for the Oklahoma chapter of Postpartum Support International. One of the new resources born out of this chapter was five state-specific support coordinators who provide resource coordination throughout Oklahoma.

The work group at the Oklahoma State Department of Health continued to shift and evolve, with some members leaving the group while new members were added. In total, the membership was relatively consistent.

 

Challenges:

The number of mental health professionals in Oklahoma with specific training in PMADs continued to be much smaller than the need. Mental health providers in rural Oklahoma were especially rare, and those who were appropriately trained in treating these concerns frequently have longer waiting lists to access services as a result of the relatively small pool of trained professionals.

 

Awareness and education remained a challenge, as many women consulted who have recently been or are currently pregnant report anecdotally that there continued to be a lack of education regarding PMADs.

 

Although there was an increase in providers who were engaging in screening for PPD, the overall availability of providers in rural Oklahoma remained insufficient; with many women traveling across county lines or in some cases not seeking sufficient prenatal care. As a result, many women continued to remain undiagnosed and untreated during and after pregnancy.

 

The number of outpatient treatment providers who were willing and available to treat maternal mood disorders continued to be small; and there were no dedicated inpatient facilities in Oklahoma for mothers (or fathers) with a need for intensive treatment especially in regards to postpartum psychosis.