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 (2015-2017), 86.5% of new mothers in Oklahoma attended their postpartum visit with the postpartum visit rate decreasing from 88.1% in 2014-2016. Mothers who reported their pregnancy was intended had a higher postpartum visit rate (51.7%) than mothers who reported their pregnancies were unintended (30%) or they were not sure (18.3%). 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:

MCH continued to send out postcards to all women with a recent live birth reminding them of the importance of returning for their postpartum visit to follow-up on problems that may have developed during pregnancy or delivery (i.e. gestational diabetes, hypertension), and to discuss birth control, folic acid, and continuing to stay quit from smoking.

 

The “Rapid Repeat Births Among Oklahoma Teens” report was published in August 2018 using PRAMS data. Rapid repeat births (< 18 months) were most prevalent among 15 - 17 year old mothers who need parental consent for contraception outside of public health clinics with federal funding and who rely on others for transportation to appointments. Access to and use of effective birth control is linked to lower rates of unintended pregnancies in teens. According to the report, studies have shown that long-acting reversible contraceptives (LARCs) are more effective in delaying a second birth than other methods for teen child bearers and older women. Overall in Oklahoma, roughly 37% of teens less than 20 years old used a contraceptive at the time they got pregnant, however over 85% reported to be using birth control postpartum indicating some level of attendance at a postpartum visit if they utilized a hormonal method of contraception.

 

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 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 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. The goal for this Preconception CoIIN team is 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. 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-women visit.

 

Challenges:

The Oklahoma State Department of Health, in conjunction with partners with 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. The OHCA resumed work this year to split out only the postpartum visit from global billing rather than moving all services off of the global billing model. 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.

 

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) 2017 data show 4% of females under 15, 6% of females < 19 years old, 14% 20-24 year olds, 15% of 25-29 year olds, 12% of 30-34 year olds, 10% of 35-39 year olds, 10% of 40-44 and 10% of females 45 years or older with SoonerCare relied on a LARC method. This provided an overall LARC utilization rate of 14.1% for SoonerCare members in SFY 2016.

 

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, 2018, SoonerPlan provided coverage to 29,284 enrollees accounting for 3.68% 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, 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 2018 indicated 8.3% of clients relied on intrauterine devices/systems and 10.6% of clients relied on the implant for contraception. Family planning services were provided to a total of 37,342 females and males of reproductive age for calendar year 2018. Of the 37,342 clients, 6,308 relied on public insurance and 25,262 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 to purchase LARCs, waiting lists were virtually eliminated creating availability for all clients on their date of service.

 

Staff from both OSDH and OHCA provided leadership for the Association of State and Territorial Health Officials (ASTHO) team for improving access to contraception. Activities included participation in monthly network calls and face-to-face meetings. This learning community ended in May of 2018 however, work continued through the Focus Forward Initiative. Through the collaborative Focus Forward 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 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 LARC to patients. Since 2017, 15 training sessions focused on best practices in patient center counseling and hands-on LARC procedures skills have been hosted at no cost to the trainees. To date, 163 providers from across the state have been trained in the curriculum. Seventy-one percent of providers were from the two major metropolitan areas of Oklahoma (Oklahoma City/Tulsa) and 29% were from rural areas in Oklahoma. Five provider types have attended the training sessions: 1) Physician MD, 57%; 2) Physician DO, 12%; 3) Physician Assistant, 10%; 4) Advanced Practice Registered Nurse (APRN)/Certified Nurse Practitioner, 19%; 5) Certified Nurse Midwife, 2%. Four specialties were represented at the training sessions: 1) Family Practice/Primary Care, 68%; 2) Obstetrics/Gynecology, 19%; 3) Pediatrics, 9%; 4) Other (e.g. Internal Medicine, Emergency Medicine), 4%. Evaluation data from the 2017 training sessions (n=124) shows that 70 of the trainees were contracted through SoonerCare before, during, and after attending the training sessions. Of these 70 providers, only 7% had SoonerCare LARC claims 1 year prior to attending the training session, and at 1 year post training, 24% of these providers had SoonerCare LARC claims. The program also launched a website that will provide information and resources related to the program. Staff continued with 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 financial resources.

 

Reaching and educating busy physicians and other health care providers remained a challenge. Information on LARCs was provided via email, electronically through websites and OHCA Provider letters, conferences, and through the Oklahoma Perinatal Quality Improvement Collaborative. 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. Reimbursement for immediate postpartum LARCs became available in CY 2014 with 62 claims submitted during the year. The most recent data available show 120 claims paid in SFY 2017 which is down from 174 in SFY 2016.

 

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.

 

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 2016-2017 births, 51.7% of mothers reported an intended pregnancy (up slightly from the previous reporting period 49.7%), 30.0% reported an unintended pregnancy (previously 33.5%), and 18.3% reported they weren’t sure what they wanted.

 

Successes: 

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 those 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, 2018, SoonerPlan provided coverage to 29,284 enrollees accounting for 3.7% 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.

 

In October 2017, the University of North Carolina at Chapel Hill (UNC) 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 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. 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. Through collaboration and use of the Human Centered Design approach, a patient engagement tool was developed for use in all sites. The first question asked if the client wanted to be pregnant in the next year. The first pilot was completed in all seven sites between September 10th and September 28th. Feedback was received from all sites and the tool was edited for a second pilot cycle.

 

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 including Life Course Perspective for provision of health care; preconception/interconception health (preconception health indicators, health screening, prevention of birth defects); adolescent health issues           (adolescent brain, unplanned pregnancy prevention); intimate partner violence and sexual coercion; mental health issues (substance use, depression, suicide prevention); trauma informed service provision; and, fatherhood and male involvement in reproductive health.

 

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.

 

Although effective at preventing unintended pregnancies, the upfront cost of LARC methods was 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.

 

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 have access to maternity care. An additional 22 counties have limited access with the remaining 41 counties meeting the designation of a maternity care desert. This designation is 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 erects significant barriers in access to contraception to prevent unintended pregnancies 

 

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 37,342 clients in the clinic for preventive health check-ups and pregnancy tests.

 

See the previous Objective 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 5, 2018 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 health, physical activity, risks for heart disease and the positive impact being at a healthy weight can have on heart disease, diabetes, and cancer. Information for men’s health week focused on getting regular check-ups, acknowledging mental health issues and getting help, healthy eating and physical activity. 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.

 

Challenges:

A billing code was established to help track usage of the Women’s Health Assessment, however, during Comprehensive Program Review visits, chart audits indicated that the code was not consistently used this year. County staff were 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.

 

Changing electronic health records to include a preconception health assessment is 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.

 

In December of 2017 and March of 2018 a reduction-in-force which reduced statewide APRN staffing from 25 to 11, significantly impacting the ability of OSDH clinics to see clients and provide preconception health education and services. Nursing staff essential to supporting the APRNs was also significantly reduced. Funding remained a challenge as federal and state budgets faced repeated cuts and revenue failures.

 

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 2015-2017 among women aged 10-59 years was 23.8 maternal deaths per 100,000 live births. The goal of Healthy People 2020 is to reduce the Maternal Mortality rate to no more than 11.4 per 100,000 live births. This measure is 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:

The Maternal and Child Health Service (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 the Nurse Manager served as the project manager. 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, two nurse practitioners, and the nurse manager abstracted cases for review. In Oklahoma, the committee was broadly representative of medical, social and community services, and providers. 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.

 

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.

 

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 during the annual Oklahoma Perinatal Quality Improvement Collaborative held November 16, 2018, in addition to meeting other criteria. Efforts were initiated this year to identify strategies for implementing the Obstetric Care for Women with Opioid Use Disorder bundle.

 

OSDH leadership was supportive this year of developing language for proposed legislation to provide statutory authority for the MMRC. Work began to draft language for possible legislation and identify potential authors.

 

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 data base.

 

Frequently, case review summaries were missing critical information. Without legislative support for MMR activities requiring entities to provide information, full case review could not be completed and system level changes could not always be identified.

 

Continued challenges related to preconception health and pregnancy intention were identified as contributing factors for many maternal deaths. To date, the MMRC has reviewed 112 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), 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 The Oklahoma Toddler Survey (TOTS), 44.5% of new mothers were screened for postpartum depression. Almost 11% of mothers with toddlers indicated they had been diagnosed with postpartum depression (PPD) sometime after their toddler was born.

 

Successes:

MCH supported efforts into outreach and screening with partners in Tulsa, Oklahoma City, and several rural counties utilizing the Edinburgh postnatal depression scale in most county health department clinics, as well as others utilizing the PHQ-9 Patient Health Questionnaire. In the county offices, not a part of the Oklahoma City or Tulsa County catchment areas, there were 2,008 screenings conducted between October 1 2017-September 30, 2018. Within Oklahoma County, there were 222 screenings conducted during this time; and within Tulsa County 52 screenings were completed by social work staff and over 100 by nursing staff.

 

In addition, screenings and brief intervention and treatment was an ongoing focus with SBIRT (Screening, Brief Intervention, and Referral to Treatment) being expanded into the OU Family Medicine Clinic, SSM Health St. Anthony Women’s Clinic, Community Health Centers Inc., Integris Family Clinic, Stigler Health and Wellness, and more partners in line to join the project.

 

Phoenix Women’s Program opened as a new resource for women in the Oklahoma City area that, while not focused exclusively on maternal mood disorders, was an inpatient strengths-based program with a focus on trauma, substance abuse, and significant depression utilizing Trauma-Focused Cognitive Behavioral Therapy and the Trauma Recovery Empowerment Model (TREM).

 

Education and awareness continued to be a focus, with trainings conducted for the Oklahoma home visitation programs, health care providers, and behavioral health clinicians working with mothers of child-bearing age and their families.

 

The Preparing for a Lifetime Work Group continued to partner with the Oklahoma Family Network to bring awareness about PPD to families with children in the neonatal intensive care unit (NICU) and to families who had lost a child during pregnancy. In addition, a postpartum depression support group was offered in Spanish and English for eight weeks through a Central Oklahoma FIMR partnership with Variety Care (a local FQHC).

 

There was an increase in membership and diversity of the Preparing for a Lifetime Maternal Mood Disorders Work Group at the Oklahoma State Department of Health. The increased membership reflected several private-practice therapists focused directly on working with mothers diagnosed with postpartum depression, patient advocates, and a representative from the Citizen Potawatomie Nation.

 

Challenges:

There continues to be a stigma against disclosure of any mental health diagnosis, and especially PPD or other maternal mood disorder. In addition, many medical providers refuse to screen women for PPD or postpartum anxiety out of a concern that they do not feel there are adequate referral resources. As a result, many women continued to remain undiagnosed and untreated.

 

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