Reduce Tobacco Use in Pregnant Women – 2020 Annual Report Narrative (October 1, 2019 – September 30, 2020):

People who smoke are at an increased risk for cancer, heart disease and other major health problems. Women who smoke have a more difficult time conceiving a baby than those who do not. A woman who smokes and becomes pregnant, is more likely than a non-smoker to have a miscarriage, preterm birth and/or have a baby born with low birth weight. Smoking during and after pregnancy also increases the risk of an infant to die from Sudden Unexpected Infant Death (SUID) and can be more at risk for certain birth defects.

In 2019, the North Dakota Department of Health (NDDoH), Division of Vital Records, reported 10.3% of North Dakota women smoked during their pregnancy. This number has decreased steadily from 18.4% in 2007. The 2016 National Vital Statistics System (NVSS) reported that 32.3% of non-Hispanic American Indian (AI) women reported smoking during pregnancy, as opposed to the national average of 16.7%. According to the NDDoH Tobacco Prevention and Control Program, in 2016, the AI population in North Dakota has a notably higher tobacco use rate than the general population, with nearly half reporting tobacco use in the past 30 days.

According to the 2016 Behavioral Risk Factor Surveillance System (BRFSS) data, women continued to be more likely to receive preventative “well-woman” care if they were married, had attended college, had insurance and had an annual income of greater than $50,000. Caucasian women in North Dakota who received a “well-woman visit” decreased to 60.7% in 2016 from 67.5% in 2014. Noticeable gains were made for AI women receiving preventive care (59.83%) as compared to 49.4% in 2014. Infant mortality rates were higher in those with less than a high school education, those who received public health insurance and unmarried mothers under the age of 20. The North Dakota AI infant mortality rate reported in the NVSS for 2013-2015 was 11.4 deaths per 1,000 live births, which was more than double that of Caucasian infants, whose rate was at 5.35 deaths per 1,000 live births.

The North Dakota BABY&ME – Tobacco Free Program (BMTFP) had enrolled 168 women during the time frame of July 1, 2020 through September 30, 2020 however 244 women were enrolled for the whole year.  Birthweight data collected since July 2018 demonstrated that the average birthweight of a baby born to a BMTFP participant was, on average, 8 ounces heavier than those who were in the “pregnant smokers” category (7 pounds 9 ounces compared to 7 pounds 1 ounce). The program uses a survey to collect information from the facilitators to capture progress. The program evaluators review the data annually. Currently, the program is building an online reporting tool that will allow facilitators to see old session data. Once data is submitted into the survey, only the program evaluators can see it. This program was greatly impacted by the COVID-19 pandemic as many staff member were reassigned to other areas of needs.  Many of the visits since March 2020 were provided via telehealth. 

The 2019 North Dakota Comprehensive Tobacco Prevention and Control State Plan (State Plan) utilizes the Centers for Disease Control and Prevention’s (CDC) “Best Practices for Comprehensive Tobacco Control Programs” model which focuses on:

• Preventing initiation among youth and young adults
• Eliminating exposure to secondhand smoke
• Promoting quitting among adults and youth
• Identifying and eliminating tobacco-related disparities among specific population groups

Twenty-eight Local Public Health Units (LPHUs) and 17 health systems worked within their communities to promote cessation efforts through NDQuits referrals and use of the 5 A’s (Ask, Advise, Assess, Assist, and Arrange) during routine visits. Four LPHUs worked specifically with the pregnant smokers (add one more if you are including Lake Region). New challenges include the increased use of electronic nicotine delivery systems (ENDS) or modified risk tobacco products (MRTP). However, there has been no mechanism to collect reliable data surrounding the use of ENDS or MRTP because these are not considered or taxed as tobacco products in North Dakota Century Code, which impairs data collection. Additionally, many NDDoH’s programs do not screen for these products, which prevents participants from receiving the proper 5 A’s and further assistance to quitting tobacco. Progress has continued to be made regarding outreach and education to disparate populations and rural communities by LPHUs and cessation grantees. From October 1, 2019 through September 30, 2020, NDQuits had 40 women registered and the BABY & ME – Tobacco Free Program had 245 women registered.

The Sleep Safe North Dakota campaign placed safe sleep stickers in high-traffic areas within medical centers, grocery store baby aisles and childcare facilities throughout the state. These large vinyl stickers contained risk reduction messaging including the benefits of breastfeeding and smoking cessation/secondhand smoke exposure. Due to funding restrictions, the plan of placing this imaging on crib sheets and pillowcases in hospitals was put on hold.  These projects provided education on the benefits of safe sleep, breastfeeding and tobacco cessation, and utilized state developed materials within their communities.

Text4Baby marketing items, which originated through a partnership with the March of Dimes North Dakota Chapter, remained available at obstetric clinics and birthing facilities across the state. This program provides expectant mothers with weekly text messages which promote healthy behaviors (including tobacco cessation) and includes a variety of health-related topics throughout their pregnancy; post-partum and infant health through age one. Text4Baby items by additional facilities were disseminated upon request. Tobacco cessation information was also included in maternal and child health (MCH) publications. BMTFP promotes smokefree.gov rather than Text4Baby because it is specifically on tobacco use. 

From October 2019 to September 2020, an average of 319 women participants on WIC (pregnant, breastfeeding, and not breastfeeding) received the maternal smoking nutrition risk code at certification. The material smoking risk code is assigned to any woman participant that reports tobacco usage. That number represents an average of 15.7% of our women participants on WIC (pregnant, breastfeeding, and not breastfeeding). During that same time 200 participants/families received referral to tobacco cessation services.  The referrals are slightly lower than previous years (252 last year), but not unexpected given the decline in availability of some cessation services due to COVID-19. North Dakota WIC staff continue to screen participant about their use of tobacco as part of the nutrition assessment process during each certification appointment. Based on the information gathered during that assessment, WIC staff will provide education on the effects of tobacco use and refer to smoking cessation programs when appropriate. The smoking cessation programs that WIC staff refer to include the North Dakota Tobacco Program’s statewide NDQuits Programs (Quitline and QuitNet) as well as cessation programs in their community. Some of our local WIC programs refer participants to their community’s Baby & Me Tobacco Free smoking cessation program as well. Educational materials on drug and other harmful substance abuse information including tobacco and secondhand smoke continue to be available to local agency WIC staff to use in their counseling with families on these topics.

The interagency Birth Review Program through MCH, the NDDoH Division of Vital Records, and Developmental Disabilities Division in the Department of Human Services has continued as a major child find activity for North Dakota. Mothers enrolled in the program are indicated on the birth certifier worksheet whether they had used tobacco during pregnancy. If so, the mother is sent information on tobacco cessation and a fact sheet explaining the dangers of secondhand smoke from the Division of Special Health Services.

Title V staff continued to collaborate with the American Indian Public Health Resource Center (AIPHRC), North Dakota State University (Public Health) University of North Dakota, on the Collaborative for Improvement and Innovation Network (CoIIN) initiative to reduce infant mortality and improve health disparities in the AI population. The framework of this partnership focused on tribal outreach, engagement, and interventions that can increase rates of prenatal care, reduce tobacco use in pregnant women, encourage safe sleep practices and improve birth outcomes. 

Many accomplishments and collaborations over these last five years has strengthen the work done in North Dakota around maternal health and reducing tobacco use in pregnancy.  The partnerships within the North Dakota Department of Health has truly impacted our state to ensure better outcomes for moms and babies. These amazing accomplishments, partnerships, dedication, and time will be carried out for years to come.

The Evidence-Based Strategy Measure (ESM) chosen for this priority has been to increase the number of partnerships established to assist with the integration of tobacco cessation and prevention activities for pregnant women and women of reproductive age. Partnerships that supported this priority include:

• Local Public Health Units (LPHUs)
• Federally Qualified Health Centers (FQHCs)

• North Dakota Department of Health Tobacco Prevention and Control Program (TPCP)
• North Dakota BABY & ME – Tobacco Free Program
• NDQuits Pregnancy Rewards Program
• Tobacco Free North Dakota (TFND) Coalition
• Campaign for Tobacco-Free Kids
• North Dakota Housing and Urban Development (HUD)
• March of Dimes, North Dakota Chapter
• North Dakota Medicaid (in partnership with NDQuits)
• Women, Infants, and Children (WIC)
• American Indian Public Health Resource Center (AIPHRC), North Dakota State University
• Master of Public Health Program, North Dakota State University
• American Lung Association
• Intertribal Tobacco Abuse Coalition (ITAC) – North Dakota Smoke-Free Casino Project
• North Dakota Department of Public Instruction (DPI)
• Cribs for Kids Programs
• Sanford Health, Jamestown
• North Dakota Family Planning Program
• SafeSleep ND