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

 

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 (2016-2019), 88.0% of new mothers in Oklahoma attended their postpartum visit with the postpartum visit rate increasing slightly from 87.3% in 2016-2018. White mothers reported a higher postpartum visit rate (90.0%) than Black mothers at 85.2%, Native American mothers at 83.8% and mothers who reported their race as other at 84.3%. 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 was used to create a report on Tobacco Use During Pregnancy Among SoonerCare (Oklahoma’s Medicaid program) Mothers. Smoking during pregnancy has been associated with many adverse health outcomes both during and after pregnancy. At the time of the survey, nearly 35% of mothers covered by SoonerCare reported using tobacco in the last two years, compared to 15% reported by non-SoonerCare mothers. From 2016-2018, 25.9% of Oklahoma mothers reported smoking in the last two years and out of these, 12% of mothers reported smoking during pregnancy (in the last three months of pregnancy). Postpartum, 25% of SoonerCare mothers and 7% of non-SoonerCare mothers reported smoking. Medicaid covered approximately 56% of live births in Oklahoma. 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. With encouragement from the Oklahoma Perinatal Quality Improvement Collaborative, the Maternal Health Task Force, and the Medicaid Postpartum Affinity Workgroup, the Oklahoma Health Care Authority (OHCA) started looking into unbundling the postpartum visit for SoonerCare. Previously, the effort to unbundle all services failed but staff began exploring again the possibility of unbundling only the postpartum visit.

 

On June 30, 2020, the Oklahoma Medicaid Expansion Initiative, State Question 802, passed by a majority vote to expand Medicaid eligibility to adults ages 19-64 whose income was 138% (133% with a 5% disregard) of the federal poverty level or lower. Enrollment opened June 1, 2021 and by August 2, an additional 154,316 individuals were approved for benefits through this expansion. Of these new enrollees, 82,211 were reproductive age women between the ages of 19 and 34. Expansion offered the full benefit package for women before, during and after pregnancy.

 

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 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 resources 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 and during the postpartum period (1-8 weeks). It was administered again when the infant was between 4-6 months, at 12 months, and then annually. It could also be administered if the parent educator suspected depression at any time. Parent Educators also administered a Prenatal/ Postpartum Record which gathered information about prenatal care, type of delivery, and screens for anxiety and depression.

 

PAT personal visits and Group Connections were completed using a hybrid of in-person and virtual platforms. In-person visits were conducted based on the comfort level of the Parent Educator and the family. These visits were completed in the home, or an alternative location such as a park or library. Virtual service delivery referred to services both through interactive video conferencing technology and phone calls. Virtual visits through an interactive video conferencing platform enabled a two-way, real-time, audio-visual communication between the home visitor and parent(s), guardians, or primary caregivers and their child(ren). Virtual visits through telecommunication were visits completed via audio phone calls.

 

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 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 to encourage the client to attend the postpartum exam. In state fiscal year (SFY) 2019, the county health departments were able to post and hire positions vacated during the SFY 2018 budget crisis. Nurses worked diligently to rebuild the program to capacity following the budget crisis. However, March 2020 through July 2021, C1 nurses were required to begin providing home visitation via telephone or telehealth for their safety and for the safety of the clients due to COVID-19. In addition, the majority of nurse home visitors, as Public Health Nurses, were required to assist with emergency response efforts. C1 Nurses worked to maintain relationships with their clients despite spending as much as 80% of their time working the pandemic response. As a result, the caseloads for the C1 program significantly dropped across the state. The majority of C1 sites across the state have been able to re-build capacity to around 60-80% since July 2021.

 

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). A new preconception/interconception screening tool was developed through the Human-Centered design process. During this year, all family planning clinics switched to using this tool. Two of the team’s Healthy Start projects developed guidelines to use the tool to prepare clients for their postpartum or well-women visit. The tool was made available in five languages: English, Spanish, Burmese, Marshallese, and Zomi. Funding for this project ended in September 2021.

 

On April 23, 2021, MCH staff provided training for county health department staff on policies and procedures for maternity services to kick off the return of prenatal care in county health departments. 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.

 

MCH staff participated in the Postpartum Affinity Work Group led by OHCA with the goals of improving attendance at postpartum visits and the quality of the visits for individuals whose pregnancy was covered by Medicaid. The group worked through a multi-pronged approach which included: 1) developed a survey of new mothers to determine if they attended a postpartum visit and if not, what barriers/attitudes prevented them from attending, 2) a care coordination pilot with five women of color with comorbidities, 3) developed a newsletter for postpartum moms, and 4) explored the option of unbundling the postpartum visit from global billing. The survey elicited interesting responses but did not reach a significant response rate for generalization of data and the care management team had difficulty reaching and engaging the five women with co-morbid conditions. Due to significant turnover in staff at OHCA, the group was not able to move forward on the other activities by the end of the grant reporting year.

 

Challenges:

OSDH, in conjunction with partners at the OHCA and private insurers, were 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.

 

During the first half of the grant period, 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.

 

The biggest challenge this year continued to be the impact of COVID-19 on access to in-person health care visits, restriction of family members from health care visits with pregnant women, the continued focus on telehealth visits, and access to telehealth visits in rural areas of the state without quality wireless connections. As COVID-19 numbers waxed and waned, healthcare providers, including OSDH family planning clinics, restricted services and visitors and then allowed visitors and increased appointments only to restrict appointments and visitors again when positive cases increased and/or staff were out sick. Acute care visits still took priority for healthcare providers and for individuals, priority over preventive care. Additionally, women were sometimes afraid to come into a healthcare provider office or a hospital for fear of contracting COVID-19 from another patient. Hospitals and clinics remained understaffed and over worked.

 

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 this reporting period and consequently, current data were not comparable to the baseline data. Calendar year (CY) 2019 data showed 4.3% of 15-20 year-old females and 3.8% of 21-44 year-old with SoonerCare, relied on a LARC method. This provided an overall LARC utilization rate of 4.1%, down from 4.6% for SoonerCare members in CY 2018. Overall, 28.2% of members chose an FDA-approved most or moderately effective method of contraception.

 

Successes:

The 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 infections (STIs); pregnancy tests; tubal ligations for females age 21 and older; and vasectomies for males age 21 and older. Enrollment opened June 1, 2021 for Medicaid expansion, and by August 2, 154,316 additional individuals were approved for benefits. Of these new enrollees, 82,211 were reproductive age women between the ages of 19 and 34. Expansion offered the full benefit package for women before, during and after pregnancy. 

 

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, 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. In June of 2021, SoonerPlan covered 5.64% of enrollees. As of September 30, 2021, individuals being moved from the limited benefit package to the full benefit package and SoonerPlan, provided coverage to 13,109 enrollees accounting for only 1% of Medicaid enrollment while expansion provided coverage for 181,747 individuals accounting for 16.36% of enrollees.

 

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; 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.

 

The Family Planning Annual Report (FPAR) for calendar year 2021 indicated 6.6% of clients relied on intrauterine devices/systems and 10.1% of clients relied on the implant for contraception. This equates to 16.7% of all users and 23.1% of clients choosing a hormonal method of contraception relying on a LARC method. Family planning services were provided to a total of 23,641 females and males of reproductive age for calendar year 2021 (down from 28,508 in CY 2020). Of the 23,641 clients, 4,700 relied on public insurance and 15,305 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, creating long waiting lists. With additional Children’s Health Insurance Program (CHIP) funding from Medicaid to purchase LARCs for clients less than 19 years old, most clients could receive their method of choice on their date of service. OHCA and OSDH continued the partnership through the Health Services Initiative, matching CHIP funds and state dollars.

 

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 (Long-Acting Reversible Contraceptive) 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 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, 32 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 384 providers from across the state have been trained in the curriculum. Sixty-seven percent of providers were from the two major metropolitan areas of Oklahoma (Oklahoma City/Tulsa) and 33% were from rural areas in Oklahoma. Five provider types have attended the training sessions: 1) Physician MD, 39%; 2) Physician DO, 17%; 3) Physician Assistant, 10%; 4) Advanced Practice Registered Nurse/Certified Nurse Practitioner, 34%; and 5) Certified Nurse Midwife, 1%. Four specialties were represented at the training sessions: 1) Family Practice/Primary Care, 71%; 2) Obstetrics/Gynecology, 15%; 3) Pediatrics, 9%; 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 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. Two MCH staff became trainers for Merck this year to assist with Nexplanon training for new OSDH staff and as part of the FFO program. 

 

Challenges:

The biggest challenge this year remained the impact of COVID-19 on access to in-person health care visits. LARC insertion requires a face-to-face visit with a healthcare provider and many providers restricted visits to curbside or telehealth only and/or continued to restrict the number of appointments available due to staff assigned to other duties.

 

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 and almost impossible this year. In addition, national attention was drawn to the fact that some populations felt they were being coerced into choosing LARCs based on their socioeconomic status rather than a response to their contraceptive desires. 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, access to simulators for training, and the temporary suspension of trainings during COVID-19. 

 

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 family planning 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. 

 

Objective 3: 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 2016-2019 births, 52.3% of mothers reported an intended pregnancy (a slight decrease from previous reporting period at 52.9%), 30.6% reported an unintended pregnancy (previously 29.3%), and 17.1% (previously 17.9%) reported they were not sure what they wanted. This does not reflect significant changes from the previous reporting period. 

 

Successes: 

OHCA continued provision of family planning services through SoonerPlan, the state plan amendment (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, 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. In June of 2021, SoonerPlan covered 5.6% of enrollees. As of September 30, 2021, individuals were being moved from the limited benefit package to the full benefit package and SoonerPlan provided coverage to 13,109 enrollees, accounting for only 1% of Medicaid enrollment, while Medicaid expansion provided coverage for 181,747 individuals accounting for 16.4% of enrollees.

 

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; STI/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 (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 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 the administration and monitoring of the Personal Responsibility and Education Program (PREP) grant from the Administration of Children, Youth, and Families and Family and Youth Services Bureau (FYSB). PREP funds continued to support projects in the Oklahoma City County Health Department (OCCHD) and Tulsa Health Department (THD). COVID-19 continued to have an impact on both projects and limited programming with schools; reach was significantly impacted as many schools restricted external visitors and only allowed for virtual instruction for an extended period of time during the 2020-2021 academic year. A total of 863 students participated in the evidence-based curricula implemented by the PREP projects. Additionally, project staff were re-assigned to COVID-19 mitigation efforts that held priority over PREP project activities.

 

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, strategies in youth engagement in mental health and live discussions with a youth panel, strategies and considerations for successful counseling of adolescents and young adults, child abuse and neglect reporting, human trafficking, intimate partner violence, trauma informed work with youth, and preconception health.

 

Challenges:

The biggest challenge this year remained the impact of COVID-19 on access to in-person health care visits, restriction of family members from health care visits (especially adolescents involving family in their decision to seek contraception), and access to telehealth visits in rural areas of the state without quality wireless connections. Many providers, including OSDH family planning clinics limited in-person visits that required exams/procedures and restricted other services to what could be provided curbside, through phone conversations, or through telehealth visits where available.

 

In the midst of COVID-19, 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. With COVID-19, acute care remained the priority for healthcare provider visits over preventive care visits. Additionally, clients were still afraid to come into a healthcare provider office or a hospital for fear of contracting COVID-19 from another client.

 

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 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 the Office of Perinatal Quality Improvement (OPQI), these conditions remained in 2021 as there were only 46 delivering hospitals in the state.

 

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. 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. The Focus Forward Program was successful at getting Medicaid to adopt a carve out for FQHCs to receive better reimbursement for LARCs which hopefully will make these methods more accessible 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 2021. 

 

Data:

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

 

Successes:

County health departments continued to assess preconception health with the 23,406 female clients in the clinic for preventive health check-ups and pregnancy tests. Healthy Start projects and Healthy Women, Healthy Futures continued to provide preconception information to clients when they were able to continue face-to-face visits.

 

A PRAMSgram was published this year on Preconception Health Disparities and Birth Outcomes among Foreign-Born and Native-Born Hispanic Women in Oklahoma. A PRAMSBrief also provided information on Social Support Among Oklahoma Mothers: 2016-2019.

 

See Objective 1 for information about the UNC-led Preconception CoIIN work on the Preconception Health Assessment Tool. 

 

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 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.

 

Through a new contract with Cox Media, MCH ran creative ads on streaming services with messages regarding preconception health and healthy pregnancies July – September, see two 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.  

 

                  

 

Challenges:

Due to COVID-19 response efforts, OSDH Office of Communications staff were focused on presenting up-to-date information on the status of COVID-19 infections, testing and recommendations in place of preconception health information for Women’s and Men’s Health Weeks. In previous years, information was shared through a press release, social media, and PSAs run during May and June. 

 

MCH staff was unable to share preconception health and prematurity information at the annual March of Dimes Walk or any other community health fairs this year due to COVID-19 restrictions.

 

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. Maternal mortality data for Oklahoma clearly indicated that obesity, tobacco use, and chronic health conditions played a major role in both maternal morbidity and mortality. However, 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. During COVID-19, in-person visits were reduced to medically necessary visits, limiting the opportunities to share preconception health information.

 

Objective 5: Increase the number of county health department sites appropriately utilizing the PHQ-9 tool and the new codes for positive and negative screening from 61 sites in 2020 to 90 sites in 2022. 

 

Objective 6: 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 data from the 2018-2019 The Oklahoma Toddler Survey (TOTS), 54% of new mothers were screened for postpartum depression, exceeding the 2022 goal. A little over 14% of mothers with toddlers indicated they had been diagnosed with postpartum depression (PPD) sometime after their toddler was born.

 

Due to COVID-19, the traditional process of auditing charts for the county health department sites was not possible. Therefore, it was not clear as to whether or not the health department sites were utilizing PHQ-9 “positive” and “negative” codes appropriately; therefore, data could not be run to determine rates for OSDH clients. 

 

There were consistent efforts to locate local women and men impacted by Perinatal Mood and Anxiety Disorders (PMADs) for participation in public service announcement videos, from partnering with local mental health providers, to conversations with local non-profit organizations centered in some of the communities disproportionately impacted by PMADs. However, finding individuals who were at the intersection of having been diagnosed with, or have had symptoms of PMADs who were not currently experiencing acute symptoms and were willing and able to share their stories on video was difficult, therefore, no one has yet been identified.

 

Successes:

In service of increasing awareness and education of throughout the state, the Maternal Mood Disorders Work Group worked on and completed a printed and digital version of a Postpartum Plan template. This template was designed to bring awareness to new mothers of some questions that they may not have considered impacting PMADs such as, “Would you like visitors at the hospital?”, “Who can bring you meals, and when?”, and “My partner will support me at night by…”. There were ongoing efforts to partner with hospital systems, OB/GYN clinics, and Pediatric clinics to distribute these throughout the state as resources for new parents.

 

In working toward connecting with and assessing the needs of Oklahoma medical providers such as OB/GYNs and Pediatricians, the Oklahoma Maternal Mood Disorders Work Group developed a survey. The survey was distributed to the membership of the Oklahoma Medical Board newsletter (which covers the majority of MDs throughout the state) as well as members of the Oklahoma Osteopathic Association (of which the majority of Oklahoma DOs are members). It was a short, nine question assessment which asked questions regarding how they integrated PMADs awareness and screening in their practice with questions such as, “What is the protocol for conducting screenings for postpartum depression in your clinic?”, “How could the OSDH help you in bringing education on PMADs to your office”, and “What treatment barriers exist that prevent you from providing the best care to your patients?” The responses received were reviewed and will be a powerful tool in formulating the future efforts of the Oklahoma Maternal Mood Disorders Work Group towards reducing stigma, raising awareness, and increasing resources for those impacted by PMADs throughout the state. 

 

Another unforeseen benefit of hosting the Maternal Mood Disorders work group meetings virtually, was the fact that more individuals attended from throughout the state who could not typically drive in to Oklahoma City to attend in-person. Having more individuals, and a greater variety of stakeholders at the table for these discussions, was a benefit that will carry forward into the future to allow the most diversity as possible in the work group composition.

 

Challenges:

Almost certainly, the reduced numbers in the number of clients reported as seen at the OCCHD and THD during the reporting timeframe impacted by COVID-19. However, because of the extremely low reported numbers (69 screenings reported at OCCHD and 72 screenings at THD), there were likely other issues as well, such as reporting inconsistencies, that cannot be ruled out until chart audits are completed.

 

Anecdotal conversations with women in the perinatal-period screened during this time have indicated that there continued to be a need for education regarding PMADs, with reports that OBGYN and Pediatric providers were not consistent in providing education on this topic.

 

In addition, although the state continued to grow the number of mental health providers who have been educated on treatment for perinatal health concerns, these numbers need additional growth; especially in more rural areas. There remained no in-patient facility in Oklahoma specifically devoted for mothers (or fathers) with a need for intensive treatment in regards to postpartum psychosis. 

 

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 21.0 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 2018-2020 among women aged 10-44 years was 25.2 maternal deaths per 100,000 live births (a decrease from 29.5 for 2017-2019). 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. 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 Maternal Mortality Review Committee (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 the 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. The APM, three 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 three to five cases at quarterly meetings in April and July to identify gaps in services or possible system level changes to prevent future maternal deaths. Due to the continuing effects of COVID-19, no cases were reviewed in January or September. The top causes of death were cardiovascular, sepsis, non-cardiovascular, and hemorrhage. 

 

MCH completed the transition to the network-based Maternal Mortality Review Information Application (MMRIA) database to help states collect and report comparable data. Cases began to be abstracted directly into this database and reviewed prior to the meetings. Committee members came prepared to discuss the cases which allowed the committee to complete 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”. The national goal was to prevent 100,000 severe complications during delivery hospitalizations and 1,000 maternal deaths over the course of the funding period. 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 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 and hospitals started 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 were recognized as “Spotlight Hospitals” for establishing protocols and entering data into the AIM data portal, in addition to meeting other criteria annually during the OPQIC summit. However, the summit was cancelled in 2021 with the hopes of returning to an in-person format in 2022. 

 

The Infant Mortality Alliance (IMA) began focusing on preventing maternal mortality as well as infant mortality at the October 2019 summit. Plans were made to host a webinar series in place of the 2020 annual summit with Dr. Joia Crear-Perry as the first speaker in October. Monthly newsletters highlighted the risks of COVID-19 for pregnant women and infants and the importance of getting vaccinated and the benefits of the Build Back Better Act nationally, which included provisions aimed at improving maternal health and covered the effects of tobacco on maternal health, including the link to cardiovascular disease, the leading cause of maternal deaths in Oklahoma.  

 

The Oklahoma Maternal Health Task Force, created in connection with the State Maternal Health Innovation Grant, finalized the strategic profile for 2020-2024, defined maternal health, and established work groups for the four priority pillars: Improve Access to Appropriate Care and Maternal Health Programs; Expand Mental Health, Substance Use and Social Services; Implement Innovative Technology and Data Systems; and Address Racial Disparities.

 

The second annual Oklahoma Maternal Health, Morbidity, and Mortality Report was released in September 2021. 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 Maternal Mortality Committee case reviews, and recommendations from the committee 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-mortality/maternal-morbidity-mortality-annual-report-2021.pdf.

 

Challenges:

COVID-19 restrictions prevented the MMRC from meeting in January and contributed to not meeting quorum in September. The committee met and approved the second annual report in October 2020 but was unable to review cases. Many members could not access the cases for review prior to the meeting despite the cases being available through several virtual yet secure options. The meeting was still held virtually and staff attempted to share the screen for the committee to review cases, but this did not prove to be an effective solution. For the September 2021 meeting, several members ended up with COVID-19 or being exposed and could not attend the in-person meeting.

 

Although Oklahoma’s maternal mortality rates remained high, the relatively small number of annual cases and small number of cases reviewed this year made it challenging to identify any new system level interventions to improve morbidity and prevent mortality.

 

Continued challenges related to preconception health and pregnancy intention were identified as contributing factors for many maternal deaths. To date, the MMRC reviewed 134 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.