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 95.0% in 2020.

 

Data:

According to the most recent 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 were used to create the Oklahoma Maternal and Child Health Data Review. Preconception and chronic health data in the review indicated that Oklahoma women reported higher rates of diabetes (3.5%) and depression (16.4%) than the national rates of 3.1% and 12.8%, higher rates of smoking in the three months prior to pregnancy (23.4% Oklahoma, 17.7% nationally) and higher rates of obesity (31.8% Oklahoma, 25.3% nationally). Oklahoma mothers also reported higher rates of postpartum depression (15.2% vs. 12.5%). These data supported the need for preventive medical visits as an opportunity for preconception counseling and the importance of the postpartum visit for follow-up and intervention if needed.

 

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.

 

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, at 12 months, and then annually. Also, it could be administered at any time if the parent educator suspected depression.

 

At the beginning of SFY 2021, with the continuing uncertainty of the pandemic health crisis, PAT made allowances to complete home visiting services using virtual platforms and Group Connections. Virtual service delivery refered to services both through interactive video conferencing technology and phone calls. Virtual visits through an interactive video conferencing platform allowed there to be two-way, real-time, audio-visual communication between the home visitor and parent(s), guardians, or primary caregivers and their child(ren). These visits were delivered using a device, preferably a tablet or computer (laptop) and a secure video conferencing platform. 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 addressed life course development (including Personal Health, Environment, Family and Friends, and Maternal Role) with the client in the prenatal period. During the C1 postpartum visit, the nurse asked when the client’s next appointment with the delivery provider was to occur. Visits from the C1 nurse 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 way to encourage the client to attend the postpartum exam. In 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. However, the pandemic significantly impacted the ability to provide home visitation services. In March 2020, as a result of the Coronavirus, Children First nurses were required to begin providing home visitation via telephone for their safety and for the safety of the clients. In addition, the majority of nurse home visitors, as Public Health Nurses, were required to assist with emergency response efforts. Children First 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 Children First Program significantly dropped across the state.

 

In October 2017, the University of North Carolina received new funding to reduce infant mortality and improve birth outcomes by advancing the status of women's preconception health particularly for low-income women and women of color in some of the country's most underserved communities. Oklahoma was chosen to participate in this grant opportunity based on work with previous Collaborative Improvement and Innovation Network (CoIIN) teams focused on preconception health. MCH recruited seven partners for this team: two family planning clinics, all four Healthy Start Projects in the state, and a Federally Qualified Health Center (FQHC). The FQHC dropped out of the project but the remaining six sites remained engaged. A new preconception/interconception screening tool was developed through the Human-Centered design process and piloted in all sites. The pilot was completed in September and all sites have incorporated the tool into their protocol. Family planning clinics and home visitation programs both restricted in person visits due to COVID and utilization of the tool with feedback from clients was limited. Two of the Healthy Start projects involved in this team 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.

 

Challenges:

The Oklahoma State Department of Health, in conjunction with partners at the Oklahoma Health Care Authority (OHCA, the State’s Medicaid agency) and private insurers, have been unsuccessful in attempts to change the rate methodology for reimbursement for obstetrical services, splitting out the postpartum visit from the global package. Consequently, it remained difficult to determine how many women actually returned for their postpartum visit. Current information on postpartum visits was obtained from PRAMS, which relied on the mother’s recall and ability to have completed the postpartum visit at the time of the survey.

 

During the grant time 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 was the impact of COVID-19 on access to in person health care visits, restriction of family members from health care visits with pregnant women, changing the focus to telehealth visits, and access to telehealth visits in rural areas of the state without quality wireless connections. Many providers, including OSDH family planning clinics, restricted services to what could be provided curbside, through phone conversations, or through telehealth visits where available. Acute care became the priority for healthcare provider visits over preventive care. Additionally, women were afraid to come into a healthcare provider office or a hospital for fear of contracting COVID from another patient/client.

 

Objective 2. Improve birth intention by increasing the usage of the most effective methods of contraception among women with Medicaid and at risk for unintended pregnancy from 12.0% in 2014 to 15.5% in 2020.

 

Data: 

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

 

Successes:

The Oklahoma Health Care Authority (OHCA) continued provision of family planning services through SoonerPlan, the state plan amendment (SPA). SoonerPlan provided coverage for uninsured men and women 19 years of age or older who were United States citizens or qualified aliens, residents of Oklahoma, not eligible for regular Medicaid, and who met the income standard. Services provided included: physical exams related to family planning, birth control information, methods, and supplies; laboratory tests including pap smears and screening for sexually transmitted diseases (STDs); pregnancy tests; tubal ligations for females age 21 and older; and, vasectomies for males age 21 and older.

 

OSDH continued to support eligibility staff in all county health departments trained to assist clients with the online enrollment process to help link clients with services (including contraception). Eligibility was determined (for any Medicaid program including Title XIX, SoonerPlan, Insure Oklahoma) at the time of application and clients were immediately provided with a Medicaid ID number to use in covering the cost of services for that day, as well as, setting up appointments if referrals were indicated. As of September 30, 2020, SoonerPlan provided coverage to 39,485 enrollees accounting for 4.36% of Medicaid enrollment which is up from 28,444 enrollees and 3.60% of Medicaid enrollment in the previous year.

 

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 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 2020 indicated 7.6% of clients relied on intrauterine devices/systems and 12.2% of clients relied on the implant for contraception. This equates to 14.0% of all users and 19.8% of clients choosing a hormonal method of contraception relying on a LARC method. Family planning services were provided to a total of 28,508 females and males of reproductive age for calendar year 2020 (down from 35,958 in CY 2019). Of the 28,508 clients, 5,225 relied on public insurance and 18,840 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.

 

Through the collaborative Focus Forward Oklahoma Initiative, the Oklahoma Health Care Authority (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 of 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, 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. This past year, policy work focused on creating a LARC carve out for FQHCs so that they could be reimbursed for LARC outside of the prospective payment system. Education efforts have focused on provider workforce development to increase the number of providers who provide LARC to patients. Since 2017, 29 training sessions focused on best practices in patient centered counseling and hands-on LARC procedures skills have been hosted at no cost to the trainees.

 

A total of 334 providers from across the state have been trained in the curriculum. Sixty-eight percent of providers were from the two major metropolitan areas of Oklahoma (Oklahoma City/Tulsa) and 32% were from rural areas in Oklahoma. Five provider types have attended the training sessions: 1) Physician MD, 41%; 2) Physician DO, 16%; 3) Physician Assistant, 10%; 4) Advanced Practice Registered Nurse/Certified Nurse Practitioner, 31%; 5) Certified Nurse Midwife, 1%. Four specialties were represented at the training sessions: 1) Family Practice/Primary Care, 72%; 2) Obstetrics/Gynecology, 15%; 3) Pediatrics, 8%; 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 Focus Forward program.

 

Challenges:

The biggest challenge this year was 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 visits only.  

 

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 became almost impossible this year. The OSDH, OHCA, and Oklahoma Perinatal Quality Improvement Collaborative all attempted to educate health care providers and promote LARCs – including postpartum LARC insertion. However, some providers were still hesitant to counsel on and insert the most effective methods, especially immediate postpartum LARCs. In addition, national attention has been drawn to the fact that some populations feel LARCs are being promoted to them as a method of population control and 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 the pandemic.

 

Religiously affiliated hospital systems managed a large number of smaller hospitals and physician practices and LARCs could not be provided immediately postpartum in those hospitals. Frequently, they could not be provided in the physician offices either for physicians associated with those hospital systems. Clients were referred to another provider when they chose a LARC method for contraception, erecting significant barriers especially in rural areas of the state. Oklahoma’s large rural population primarily relies upon local public health department clinics to provide publicly supported family planning services. According to the 2015 Oklahoma Health Work Force Data Book, 66 of Oklahoma’s 77 counties were designated as health professional shortage areas.

 

Smaller hospitals, physician practices, and some Federally Qualified Health Centers faced financial barriers in purchasing LARCs and having them available for same day insertion. Some hospitals and providers were still unaware that LARCs could be placed immediately postpartum and billed separately from the global delivery charge.

 

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

 

Data:

PRAMS data were used to monitor unintended pregnancy within Oklahoma. For 2016-2019 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). See Objective 2 for more information on this program.

 

OSDH continued to support eligibility staff in all county health departments trained to assist clients with the online enrollment process to help link clients with services (including contraception). Eligibility was determined (for any Medicaid program including Title XIX,  SoonerPlan, Insure Oklahoma) at the time of application and clients were immediately provided with a Medicaid ID number to use in covering the cost of services for that day, as well as, setting up appointments if referrals were indicated. As of September 30, 2020, SoonerPlan provided coverage to 39,485 enrollees accounting for 4.36% of Medicaid enrollment which is up from 28,444 enrollees and 3.60% of Medicaid enrollment in the previous year.

 

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

 

See Objective 1 for information on the Preconception CoIIN project.

 

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

 

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

 

MCH continued to receive funding through the federal Personal Responsibility Education Program (PREP) grant to maintain teen pregnancy prevention efforts. PREP funds continued to support projects in the Oklahoma City County Health Department (OCCHD) and Tulsa Health Department (THD). Both projects continued to build connections with schools even during the pandemic. Due to local health department staff being largely re-assigned to COVID mitigation efforts and schools being either online-only or closed to visitors, the evidence-based curricula: "Making a Difference!", "Making Proud Choices!”, “Love Notes”, “Positive Prevention Plus” and “Power through Choices” were not facilitated for most of this grant year. Projects did provide some limited online content, including curriculum, but the reach was not very large.

 

Staff development opportunities were provided throughout the year based on the MCH annual staff development training needs assessment as well as federal Title V and Title X Family Planning priorities and key issues. These trainings included anticipatory guidance and family participation for adolescents seeking family planning services; intimate partner violence and sexual coercion; human trafficking; infections and reproductive health; recommended immunizations; and substance use and misuse in pregnancy. Only a few of the scheduled trainings were provided due to staff being reassigned to emergency response activities.

 

Challenges:

The biggest challenge this year was 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), changing the focus to telehealth visits, and access to telehealth visits in rural areas of the state without quality wireless connections. Many providers, including OSDH family planning clinics restricted services to what could be provided curbside, through phone conversations, or through telehealth visits where available.

 

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 the pandemic, acute care became the priority for healthcare provider visits over preventive care visits. Additionally, clients were afraid to come into a healthcare provider office or a hospital for fear of contracting COVID from another patient/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 CNM providers per 100,000 population, and the proportion of women 16-64 without health insurance. A lack of these health care providers erected significant barriers in access to contraception to prevent unintended pregnancies. Only 27 out of 77 counties had a hospital capable of delivering infants.

 

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

 

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

 

Data:

The number of service sites utilizing the Women’s Health Assessment Tool developed by the Oklahoma State Department of Health (OSDH) or any alternative tool remained constant this year. Every county health department utilized the Women’s Health Assessment/Client Engagement Tool 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 assess preconception health with the 28,273 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 as long as they were able to continue face-to-face visits.

 

PRAMS data were used to develop the Oklahoma Maternal and Child Health Data Review fact sheet with information on preconception health indicators including chronic conditions, birth rate, teen birth rate, smoking in the three months prior to pregnancy, alcohol use in the three months prior to pregnancy, multivitamin/folic acid use, and obesity. Oklahoma’s rates were worse than national rates for all indicators except birth control use postpartum (79.6 to 77.0 respectively) and multivitamin use (41.9 to 40.4).

 

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

 

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:

Due to COVID response efforts, 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 not able 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 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. Prior to COVID, 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 the pandemic, in-person visits were reduced to medically necessary visits, limiting the opportunities to share preconception health information. The sites piloting the new CoIIN tool did experience significantly more buy-in and discussion regarding health behaviors and risks before the preventive visits suspended.

 

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 2017-2019 among women aged 10-59 years was 20.8 maternal deaths per 100,000 live births (down from 24.9 for 2016-2018). The goal of Healthy People 2020 was to reduce the Maternal Mortality rate to no more than 11.4 per 100,000 live births. This measure was based on a three-year rate of those deaths occurring within forty-two days from termination of pregnancy to assure the availability of comparable data to other state and national rates. For confidentiality reasons, MCH policy for reporting Oklahoma maternal mortality rates required that only three-year rolling averages could be released.

 

Successes:

MCH continued to provide leadership for the Maternal Mortality Review. Oversight was provided by the Perinatal and Reproductive Health Division (PRHD) Administrative Program Manager (APM) and one of the Advanced Practice Nurses continued in the project manager role. With the passage of HB 2334, the Maternal Mortality Review Committee became a statutory committee with expanded access to additional records vital for accurate case review. The Maternal Mortality Review Committee (MMRC) remained an essential community process used to enhance and improve services to women, infants and their families. Qualitative, in-depth reviews investigated the causes and circumstances surrounding each maternal death. Through communication and collaboration, the MMRC served as a continuous quality improvement system that resulted in a better understanding of the maternal issues. The overall goal of the MMR was prevention through understanding of causes and risk factors. The list of maternal deaths, obtained from the Vital Records Division, was reviewed by the APM and the PRH Medical Director to determine which cases would be reviewed by the committee. All possible pregnancy-related and pregnancy-associated deaths were reviewed for women who died while they were pregnant or within 365 days of the end of the pregnancy. The APM, three nurse practitioners, and the nurse manager abstracted cases for review. HB2334 defined the make-up of the committee with 18 permanent positions representing various organizations and disciplines, as well as seven community positions appointed by the Commissioner of Health. The committee reviewed three to four cases at quarterly meetings in October and January to identify gaps in services or possible system level changes to prevent future maternal deaths. The top causes of death were cardiovascular, sepsis, non-cardiovascular, and hemorrhage.

 

MCH continued to work with the CDC as the transition to the network-based Maternal Mortality Review Information Application (MMRIA) database was completed to help states collect and report comparable data. Cases are now abstracted directly into this database.

 

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 is 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 Office of Perinatal Quality Improvement (OPQI) continued to provide leadership for these efforts providing technical assistance for participating hospitals on data entry, policy development, and emergency drills. The participating Oklahoma birthing hospitals worked on postpartum hemorrhage and/or hypertension. Information on outcome measures was entered into the database through the Vital Records Division. Process measure information was entered by individual hospital staff. Hospitals were recognized as “Spotlight Hospitals” for establishing protocols and entering data into the AIM data portal, in addition to meeting other criteria. During the summit in 2019, the tool kit for the Obstetric Care for Women with Opioid Use Disorder bundle was presented to hospital staff to kick-off work on this bundle. Fifteen hospitals agreed to participate in this bundle, however, hospital staff were diverted to acute care with the pandemic and opioid bundle activities were suspended in the spring. Plans are to resume as soon as staff can transition back to regular duties and responsibilities.

 

The Infant Mortality Alliance (IMA) began focusing on preventing maternal mortality as well as infant mortality. At the October 2019 Summit, Dr. Malawa provided guidance on “Naming the Elephant in the Room” in order to start the conversation on racism and its effects on infant and maternal mortality. In July, the IMA hosted a panel discussion with a senator, representative and two city council members to discuss current events, policy implications and insights for reducing infant and maternal mortality in Oklahoma County. 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.

 

Challenges:

COVID restrictions prevented the MMRC from meeting in April and July. The committee met and approved the first annual report in October 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. With multiple options available for virtual meetings/document sharing and differing agency restrictions on platform utilization, staff experienced difficulty orienting outside partners to the OSDH approved Teams platform.

 

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

 

Transition to the new MMRIA database occurred this year but since hospitals restricted access to records during the pandemic, staff were not able to fully utilize and become familiar with the database.

 

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

 

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

 

Data:

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

 

Successes:

In this timeframe, MCH worked to unify the screening for postpartum depression across programs, asking each clinic to utilize the PHQ-9 Patient Health Questionnaire. By having each area (WIC, family planning, child guidance) utilize the same screening tool more uniform data were collected and program staff could better determine trends in their communities. These screenings continued with the county health department clinics throughout the state, and with partners in the Tulsa and Oklahoma City County Health Departments.

 

The primary goals of the Preparing for a Lifetime Maternal Mood Disorders Work Group continued to be ongoing reduction in stigma, increased awareness, and provision of education both to the general public and to medical providers throughout the state. Despite the COVID-19 pandemic restricting in-person gatherings, educational opportunities were found in places critical for this education. The co-lead of the Maternal Mood Disorders Work group trained home visiting staff in the southeastern area of Oklahoma in recognizing Perinatal Mood and Anxiety Disorders (PMADs) as well as how they could best educate their clients on the symptoms to look for, give their own overview to their clients, and tools for prevention and intervention.

 

Planning and registration was completed for the Postpartum Support International (PSI) Components of Care and Advanced Psychotherapy virtual trainings coming to Oklahoma for perinatal behavioral health providers. These trainings will be a vital tool to both increase substantive education in detail on perinatal mental health for mental health clinicians throughout the state as well as a tool to increase resources for OB/GYN, pediatrician, and other medical providers. Although originally scheduled for June 2020, the trainings were postponed due to concerns about coronavirus as the event was originally designed to be in-person. The event was rescheduled for virtual implementation in December 2020.

 

Challenges:

As with many programs and sectors of public health, COVID-19 had impacts on maternal mental health and the mitigation efforts of the Preparing for a Lifetime Maternal Mood Disorders Work Group. Perhaps one of the most unfortunate impacts was the drop in screenings for postpartum depression across the state at health departments and contract sites. At both local county health departments and partner sites at independent health departments the Tulsa Health Department (THD) and Oklahoma City-County Health Department (OCCHD) the overall number of screenings from October 1, 2019 to September 30, 2020, decreased by 22.1% over the previous report to 1,673. This is most likely due to the decreased number of women who came into family planning clinics, WIC offices, or county health departments for other needs because of provider restrictions or anxieties about the virus. Unfortunately, the need for screening and treatment was possibly as great or greater due to the impacts of COVID-19 on the mental health of mothers, fathers, and families.

 

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

 

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