NPM 1: Percentage of women, ages 18 through 44, with a preventive medical visit in the past year
Objective 1. Increase the number of women returning for the postpartum visit from 87.3% in 2016-2018 to 96.0% in 2025.
Data:
According to the latest available Oklahoma Pregnancy Risk Assessment Monitoring System (PRAMS) data (2016-2019, 2021), 88.0% of new mothers in Oklahoma attended their postpartum visit. For the 2021 data, White mothers reported a higher postpartum visit rate (90.9%) than Black mothers at 82.9%, Native American mothers at 80.9% and mothers who reported their race as Other at 83.8%. The White rate increased slightly in 2021 from 90.0% to 90.9% while the rate of postpartum visit attendance dropped slightly in all other race categories maintaining the overall rate of 88.0%. 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.
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 (CHD) 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:
PRAMS data were used to create several publications: Social Support Among Oklahoma Mothers (December 2021), Profile of Oklahoma Mothers Who Used Prescription Opioids During Pregnancy (February 2022), and Pre-Pregnancy Binge Drinking and Maternal Mental Health (July 2022). Ninety percent of Oklahoma mothers reported they had someone to help them if they felt tired or frustrated and 88.8% reported they had someone to help take care of the baby. This report did not assess access to transportation to attend health visits including the postpartum visit. Oklahoma mothers were more likely to use prescription opioids for pain relief (9.7%) than the overall U.S. rate (6.6%). Mothers whose births were covered by Medicaid were more likely to use opioid pain relievers (11.4%) than mothers who had another type of insurance (8.6%). Non-Hispanic Black mothers reported the highest use of prescription opioids. Within the binge drinking study, a high percentage of mothers who engaged in binge drinking reported experience with the criminal justice system, having someone close with a drinking or drug problem, having a partner who did not want the pregnancy, or going through separation or divorce. These data support the need for continued education about preventive medical visits prior to pregnancy, early prenatal care, and attendance at postpartum visits.
The Soon-To-Be-Sooners Medicaid plan continued in the state but was a limited benefit plan with coverage ending at delivery; therefore, the postpartum visit was not covered. Consequently, women who qualified for this package may not have returned for their postpartum visit and health care providers were not motivated to encourage these mothers to return in the absence of medical conditions requiring follow-up. The Oklahoma Perinatal Quality Improvement Collaborative (OPQIC), the Maternal Health Task Force, and the Oklahoma Health Care Authority (OHCA) worked to support efforts to expand Medicaid postpartum coverage to 12 months, which became effective January 1, 2023. However, it does not apply to mothers covered under the Soon-To-Be-Sooners plan.
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 over 300,000 individuals were approved for benefits through this expansion in the first year. 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.
CHD staff continued to encourage women to return to their delivering provider for a postpartum visit. For those women who refused to return to the delivering provider, the advanced practice nurse in the CHD conducted a postpartum visit, follow-up, or referral for follow-up, on any health conditions that developed during pregnancy (i.e., gestational diabetes, hypertension) and encouraged the use of the moderately or most effective methods of contraception as indicated through client-centered counseling.
Children First (C1), Oklahoma's Nurse-Family Partnership, continued to provide a voluntary family support program that offered home visitation services to mothers expecting their first child. Upon enrollment, a public health nurse worked with the mother in order to increase her chances of delivering a healthy baby. The nurses assessed clients in six domains during the prenatal period: Personal Health, Environment, Family and Friends, Life Course Development, Maternal Role, and Health and Human Services. During the C1 postpartum visit, the nurse asked when the client’s next appointment with the delivery provider was to occur. Visits from the C1 nurse were scheduled weekly for the first 4 visits, every other week until the baby is born and 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 to encourage the client to attend the postpartum exam. From 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 their adjusted capacity to approximately 80% or greater since July 2021.
In June, all family planning clinics switched to using the new Preconception Screening Tool that was developed as part of a Human-Centered Design project with the University of North Carolina. The tool was made available in five languages: English, Spanish, Burmese, Marshallese, and Zomi. This tool was used to start a conversation about preconception/interconception reproductive health and plans regarding future pregnancies to tailor client-centered care to the needs of each individual client. Staff took the opportunity to remind clients of the importance of returning for their postpartum visit (if applicable) and getting regular annual exams.
Family planning clients with a positive pregnancy test continued to be counseled on the need to initiate care with a maternity health care provider within 15 days. Four CHDs initiated maternity services in the spring, increasing access to early prenatal care. For clients choosing to follow up with the CHD for prenatal care, the initial prenatal lab work could be drawn during the pregnancy test visit and an appointment scheduled with the APRN. Twenty clients received prenatal care through OSDH in this grant period. Most of them either returned to the delivery provider or did not attend the postpartum visit. 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.
Family planning providers across the state started the transition from pandemic COVID-19 response to an endemic response. Advanced practice providers, nursing and support staff slowly returned to primary responsibilities and consequently, the Family Planning Annual Report (FPAR) showed an increase in the number of clients seen from 23,641 in 2021 to 25,961 during CY2022, for their annual preventive health 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. Due to significant turnover in staff at OHCA, the group changed goals and objectives numerous times and was not able to move forward with a specific project by the end of the grant reporting year. Interaction with different OHCA staff did bring a broader awareness of the current programs and services available. The members of the work group also supported efforts to extend Medicaid coverage for 12 months postpartum.
New Community Health Workers were trained regarding reproductive health services and how to link individuals to OSDH services and other reproductive health services in the community.
Challenges:
OSDH, in conjunction with partners at the OHCA and private insurers, continue to struggle with splitting the postpartum visits from the global package. Consequently, it remained difficult to determine how many women actually returned for their postpartum visit. Current information on postpartum visits was obtained from PRAMS, which relied on the mother’s recall and ability to have completed the postpartum visit at the time of the survey. The Postpartum Affinity work group researched information from other states and considered options including adding a billing code, offering incentives, and asking providers to participate in a pilot for voluntarily reporting information. However, none of these suggestions were deemed as a viable option for change.
Even though Oklahoma did expand Medicaid, the limited benefit package for Soon-to-be-Sooners recipients continued to end at delivery so it did not cover the postpartum visit. The lack of health care providers in rural areas made it difficult for some women to attend a postpartum visit due to limitations of time and transportation. Due to the large percentage of working mothers without paid leave, many new mothers were forced to return to work early, making it difficult to attend postpartum and newborn health care visits.
Another challenge this year continued to be the impact of COVID-19. As COVID-19 numbers waxed and waned, OSDH healthcare providers were required to assist with testing and vaccinations. Monkey Pox response activities also took nurses away from regular clinic responsibilities. Acute care visits still took priority for many healthcare providers and for individuals 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.
Nursing vacancies within the C1 Program impacted the number of clients staff were able to serve.
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. Data reported this year from the OSDH FPAR indicated that 21,975 (85%) unduplicated clients were covered by Medicaid or considered uninsured. For the purposes of this report, the uninsured category includes individuals covered by SoonerPlan since it is not a full benefit plan. The FPAR for calendar year 2022 indicated 6.4% of all female clients relied on intrauterine devices/systems and 10.3% of female clients relied on the implant for contraception. This equates to 16.7% of all users and 25.5% of clients choosing a hormonal method of contraception relying on a LARC method. Family planning services were provided to a total of 25,961 females and males of reproductive age for calendar year 2022 (up from 23,641 in CY 2021). Of the 25,961 clients, 12,465 relied on public insurance (up from 4,700 in 2021 before individuals could enroll for Medicaid expansion) and 9,510 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). There were three Title X grantees in the state and the statewide FPAR report released in September 2022 (for CY 2021) indicated that 28,371 unduplicated clients were seen statewide with 95% reporting incomes < 250% FPL. Using the same Medicaid definitions above, 84% were covered by public health insurance or uninsured. Of these 28,371 clients, 22% relied on a most effective method of contraception and 60% relied on a moderately effective method of contraception.
Successes:
Since the public health emergency was still in effect, OHCA continued provision of family planning services through SoonerPlan, the state plan amendment (SPA) as well as expanded Medicaid services known as SoonerChoice. SoonerPlan provided coverage for uninsured men and women 19 years of age or older who were United States citizens or qualified aliens, residents of Oklahoma, not eligible for regular Medicaid, and who met the income standard. Services provided included: physical exams related to 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 which offered the full benefit package for women before, during and after pregnancy. OHCA worked to move individuals off SoonerPlan and on to SoonerChoice coverage. As of September 30, 2022, SoonerPlan provided coverage to 6,795 individuals (down from 13,109 last year), accounting for only 0.8% of Medicaid enrollment while expansion provided coverage for 324,142 enrollees accounting for 24.85% of enrollees.
Family planning services were provided through CHDs 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.
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 devices for SoonerCare members from the Oklahoma State Plan for Medicaid, worked in partnership with OSDH to develop a Health Service Initiative through CHIP to increase the number of LARC devices available to uninsured women under 19, and created a LARC carve-out for federally qualified health centers (FQHCs), so that they can be reimbursed for LARCs outside of the prospective payment system. Efforts to best address inventory management for LARC are underway this year. Education efforts have focused on provider workforce development to increase the number of providers who provide LARCs to patients. Since 2017, 32 training sessions focused on best practices, “in-patient”-centered counseling and hands-on LARC procedure skills hosted at no cost to the trainees. A total of 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 impact of COVID-19 remained a challenge this year. LARC insertion requires a face-to-face visit with a healthcare provider and many providers continued to restrict the number of appointments available due to staff assigned to other duties and for safety reasons.
Three additional major challenges continued to impede progress towards reaching this goal: education, religiously affiliated hospital systems, and access to providers in rural areas of the state.
Reaching and educating busy physicians and other health care providers remained a challenge this year. 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. Client-centered counseling trainings were provided through the Reproductive Health National Training Center. LARC trainings through the FFO program were all provided in Oklahoma City and Tulsa. Training was scheduled in several locations around the state but were cancelled due to low response rates and logistics. Therefore, no training was provided for clinicians in the western half of the state.
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.
Health Care Access Objective 1: Reduce the rate of unintended pregnancies (mistimed or unwanted) among mothers who have live births from 29.3% in 2016-2018 to 25.0% by 2025.
Data:
PRAMS data were used to monitor unintended pregnancy within Oklahoma. For 2021 births, 53.6% of mothers reported an intended pregnancy (a slight increase from previous reporting period at 52.3%), 27.5% reported an unintended pregnancy (previously 30.6%), and 19.1% (previously 17.1%) 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, SoonerChoice, or Insure Oklahoma) at the time of application, and clients were immediately provided with a Medicaid ID number to use in covering the cost of services for that day, as well as, setting up appointments if referrals were indicated. Enrollment opened June 1, 2021, for Medicaid expansion which offered the full benefit package for women before, during and after pregnancy. OHCA worked to move individuals off SoonerPlan with the limited benefit package and on to SoonerChoice coverage with a full benefit package. As of September 30, 2022, SoonerPlan, provided coverage to 6,795 individuals (down from 13,109 last year) accounting for only 0.8% of Medicaid enrollment while expansion provided coverage for 324,142 enrollees, accounting for 24.85% 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/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 2 for a discussion about LARC activities, supplemental funding, and professional training opportunities.
Staff employed in MCH administered the federal Title V, Title X and Personal Responsibility and Education Program (PREP) funds. Many activities between these programs overlapped to prevent unintended pregnancies.
MCH continued the administration and monitoring of the PREP grant from the Administration of Children, Youth, and Families (ACF) and Family and Youth Services Bureau (FYSB). The federal funds supported the implementation of TPP projects through contractual agreements with the Oklahoma-City County Health Department (OCCHD) and the Tulsa County Health Department (THD). Target populations remained youth 11-19 years of age in the middle, high, and alternative schools in the Oklahoma City and Tulsa MSAs. PREP projects continued to use evidence-based curriculum from the Health and Human Services (HHS) approved list; Making a Difference (MAD), Making Proud Choices (MPC), Love Notes, Positive Prevention PLUS (P3) High School (HS), P3 Middle School (MS), and Power Through Choices. A total of 4,399 students participated in PREP programming in the Oklahoma City and Tulsa metropolitan statistical areas (MSAs) during the timeframe of this report.
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 engagement with children and youth and understanding ACES/PACES, anticipatory guidance and family participation for adolescents seeking family planning, child abuse and neglect reporting, human trafficking, intimate partner violence, trauma informed work with youth, and preconception health.
CHDs continued to assess preconception health with the 25,704 female clients in the clinic for preventive health check-ups and pregnancy tests. Healthy Start projects continued to provide preconception information to clients when they were able to continue face-to-face visits.
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.
A press release in May focused on addressing five key health topics affecting women in all stages of life for Women’s Health Week. Those topics included breast and cervical screenings, congenital syphilis, heart health, preconception health, postpartum depression, and smoking and using e-cigarettes during pregnancy. A Facebook post and information on the lobby TV promoted the mobile mammogram services in addition to 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. For Men’s Health Month, MCH worked with the Office of Communications and created a social media toolkit with Facebook/Twitter messages on lifestyle decisions and health futures, fatherhood, annual screenings, Wear Blue Day, and mental health. The press release for Men’s Health Month focused on being tobacco free, drinking water, eating healthy, regular check-ups, physical activity and mental health.
Through the contract with Cox Media, MCH ran creative ads on streaming services with messages regarding preconception health and healthy pregnancies like the July – September examples below. The previously created public service announcements, Measure Up (preconception health) and Caring Dads (secondhand smoke and newborns) were also run on the streaming services.
MCH also utilized the Cox contract to run social media messages on Post-Birth Warning Signs and promotion of the OSDH maternity clinics.
Challenges:
The impact of COVID-19 remained a challenge this year as many providers continued to restrict the number of appointments available due to staff reassigned to other duties and for safety reasons. Access to care was also impacted by the restriction of family members in 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, continued limiting in-person visits for safety and staffing reasons.
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 for the first half of the year. 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 43 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.
SPM 1: Maternal Mortality rate per 100,000 live births
Objective 1: Reduce maternal mortality rate from 28.8 maternal deaths per 100,000 live births in 2016-2018 to 23.8 by 2025.
Data:
Maternal death continued to be the international standard by which a nation’s commitment to women’s status and their health could be evaluated. The Maternal Mortality Rate (maternal deaths within 42 days of termination of pregnancy per 100,000 live births) for Oklahoma from 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 (MMRC))). Oversight was provided by the Perinatal and Reproductive Health Division Administrative Program Manager (APM) and one of the Advanced Practice Nurses who continued in the project manager role. With the passage of House Bill (HB) 2334, the MMRC became a statutory committee with expanded access to additional records vital for accurate case review. The MMRC remained an essential community process used to enhance and improve services to women, infants and their families. Qualitative, in-depth reviews investigated the causes and circumstances surrounding each maternal death. Through communication and collaboration, the MMRC served as a continuous quality improvement system that resulted in a better understanding of 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. 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 two to fourteen cases at quarterly meetings from October 2021 – September 2022 to identify gaps in services or possible system level changes to prevent future maternal deaths. The top causes of death were cardiovascular conditions including cardiomyopathy, infection, and hemorrhage.
The Maternal Mortality Review Information Application (MMRIA) database continued to be used to collect and report data. Cases were abstracted directly into this database and reviewed prior to the meetings. Committee members came prepared to discuss the cases which allowed the completion of more cases during each meeting.
The Council on Patient Safety in Women’s Health Care continued to provide leadership for the program “Alliance for Innovation on Maternal Health (AIM): Improving Maternal Health and Safety”. Oklahoma was the first AIM state, based on infrastructure and activities put in place through the ‘Every Mother Counts Initiative’ in 2014. The OPQI continued to provide leadership for these efforts providing technical assistance for participating hospitals on data entry, policy development, and emergency drills. The participating Oklahoma birthing hospitals worked on postpartum hemorrhage and/or hypertension initially. Those measures transitioned to nationally reported measures, so OPQI continued to provide support for reporting those measures but began focusing more on reporting on the bundle addressing opioid use disorder. The Oklahoma Mothers and Newborns Affected by Opioids (OMNO) initiative provided data and technical support for this initiative. Information on outcome measures was entered into the database through the Vital Records Division. Process measure information was entered by individual hospital staff. Hospitals meeting certain criteria are usually recognized as “Spotlight Hospitals” annually during the OPQIC summit for participating in this initiative and other quality improvement initiatives. However, the summit was virtual in 2021 and healthcare facilities were just returning to non-COVID-19 activities for the in-person meeting in 2022; as a result, these awards were temporarily suspended until the birthing hospitals could focus on QI activities again.
The Oklahoma Maternal Health Task Force, created in connection with the State Maternal Health Innovation Grant, finalized the strategic profile for 2020-2024 last year which defined maternal health and established work groups for the four priority pillars: (i) Improve Access to Appropriate Care and Maternal Health Programs; (ii) Expand Mental Health, Substance Use and Social Services; (iii) Implement Innovative Technology and Data Systems; and (iv) Address Racial Disparities. This year, the work groups focused on activities within each domain including creating telehealth recommendations for prenatal care, supporting OHCA efforts to expand postpartum coverage to 12 months, establishing a database for maternal health data, working with the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) on interventions to support mothers with substance use disorders, training on inclusivity and compassionate care for prenatal care providers, offering training on health equity and implicit bias for health care providers statewide, and assessing resources for expanding access to midwifery and doula care.
The third annual Oklahoma Maternal Health, Morbidity, and Mortality Report was released in September 2022. 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-health-task-force/maternal_mortality_report_2022.pdf
Challenges:
COVID-19 restrictions impacted provider availability for the first part of the year. Competing priorities and travel distance still provided challenges for committee member attendance, but the committee was able to meet quorums for all meetings this year.
One of the greatest challenges was developing recommendations that addressed the social determinants of health. Committee members found it much easier to develop “clinical” recommendations that target hospitals and providers which was only one piece of the puzzle for reducing maternal mortality. Identifying actionable recommendations posed a significant challenge.
The impact of COVID-19 on maternal deaths was discussed as the committee began reviewing deaths involving a positive COVID-19 diagnosis during pregnancy or the immediate postpartum period. Discussions proved that there were significant differences in how healthcare providers viewed the impact of COVID-19 and whether or not it was the cause of death or a contributing factor for the cases reviewed. Most of these cases will be reviewed starting with the October 2022 meeting.
Continued challenges related to preconception health and pregnancy intention were identified as contributing factors for many maternal deaths. At least one of the following contributing factors was listed for the majority of cases reviewed for the latest report: obesity, substance use disorder, tobacco use, and mental health conditions.
The Infant Mortality Alliance (IMA) suspended activities temporarily due to competing priorities during the COVID-19 response this year. Plans are being discussed for initiating activities again after the first of the year. This group also focused on causes of maternal mortality that impact infant mortality, especially around health equity and access to care.
OSDH, ACOG, the Oklahoma Hospital Association, and other partners worked together again to craft legislation requiring all maternal deaths be reported to the Medical Examiner’s Office. The bill introduced in the legislature during the last legislative session, did not advance past the legislative committee level. To gain support from legislators, partners must agree to reduce the statutory size of the committee.
NPM 1: Percent of women, ages 18 through 44, with a preventive medical visit in the past year.
Objective 1: Increase the percent of county health department sites appropriately utilizing the PHQ-9 tool for screening and the new codes for positive and negative screening from 61 sites in February 2020 to 90 sites by 2025.
Health Equity Objective 1: Create culturally competent public service announcements (PSAs) and messages on maternal mental health that are representative of African American, Native, and Latinx women and men impacted by Perinatal Mood and Anxiety Disorders (PMADs) by 2025.
Data:
According to 2021 data from The Oklahoma Toddler Survey (TOTS), 58% of new mothers were screened for postpartum depression, exceeding the 2022 goal. A little over 17% of mothers with toddlers indicated they had been diagnosed with postpartum depression (PPD) sometime after their toddler was born.
A communication to CHD family planning clinics regarding the PHQ-9 screening process was made prior to the beginning of the COVID-19 pandemic, and although re-training was scheduled, it was paused due to this and other emergent public health response (syphilis outbreak).
Successes:
The Oklahoma Maternal Mood Disorders Workgroup lead participated in a community baby shower held by the Citizen Pottawatomi Nation, conducting six educational sessions on the symptoms, prevalence, treatment, and resources for Perinatal Mood and Anxiety Disorders (PMADs). There were a large number of families at the event, with a total count of 754 participants.
In June 2022, the 3rd Climb Out of the Darkness awareness walk was held in Oklahoma City, and 60 people were in attendance where several mothers shared their journeys through perinatal mental health diagnoses prior to the walk itself. Tulsa hosted their first Climb Out of the Darkness the last weekend of June, expanding awareness activities into the second largest metropolitan area in the state.
Challenges:
Although the COVID-19 pandemic had begun moving towards an endemic rather than pandemic phase, the continued need for staff to be pulled away for COVID-19 testing, as well as a statewide syphilis outbreak, meant no annual chart audits or site visits. This made gauging the efficacy of screening efforts in CHDs clinics more difficult from the Central Office.
The Maternal Mood Disorders workgroup lead connected with multiple nonprofit and community organizations, private mental health agencies, and therapists in an effort to identify additional participants for public service announcement videos. While there were several candidates identified and interviewed, no participant was identified due to lack of comfort sharing their story on video. Additional outreach was planned to identify new partners for this project. This was a particularly difficult project since the goal to find an individual to tell a personal story of perinatal mental health diagnosis potentially carried additional stigma adding to existing stigma for all mental health issues.
To Top
Narrative Search