NPM 5: A) Percent of infants placed to sleep on their backs; B) Percent of infants placed to sleep on a separate approved sleep surface; C) Percent of infants placed to sleep without soft objects or loose bedding.
Objective 1: Increase the number of hospitals participating in the Safe Sleep Sack Program from 27 in 2019 to 35 in 2025.
Objective 2: Increase the number of trainings and community outreach activities by the Infant Safe Sleep Work Group members for providers and professional organizations on infant safe sleep from 10 in 2020 to 20 in 2025.
Objective 3: Join with internal partners and outside community partners to create culturally competent public service announcements (PSAs) and messages that focus on integrating infant safe sleep and breastfeeding messages for each population with disproportionately high infant mortality rates by 2025.
Health Equity Objective 1: Increase the percent of American Indian and African American births in hospitals participating in the Safe Sleep Sack Program, from 73.3% in 2018 to 80% in 2025.
Health Equity Objective 2: Increase the number of hospitals and other facilities serving American Indian and African American families participating in the Cribs Project, distributing pack-n-plays and safe sleep tools and education for families, from 5 in 2020 to 8 by 2025.
Between October 1, 2022, and September 30, 2023, 29,004 sleep sacks were provided to families upon discharge from the 29 participating Oklahoma birthing hospitals. Among those participating hospitals, the percentage of births to American Indian women decreased to 7.7% in 2023 from 7.8% in 2022. In the African American community, the percentage of births in hospitals participating in the sleep sack program increased from 9.0% in 2022 to 9.5% in 2023. The percent of American Indian and African American births in participating hospitals increased to 75.7% in 2023 form 73.3% in 2018.
The percentage of infants placed to sleep on their backs was 83.6% according to 2021 data. This was an increase from 77.6% when compared to 2016-2019 aggregated data. However, 64.7% of African American mothers reported placing their infants to sleep on their backs, compared to 86.5% of white mothers and 81.6% of American Indian mothers. These disparities indicate a continued need for education and outreach in the African American population. Although the disparity is much smaller in the American Indian community; effort should continue to increase the percentage.
Since 2021, there have not been any new additions of hospital partners to the infant safe sleep education and sleep sack initiative.
Successes:
The Infant Safe Sleep Work Group continued to provide accurate and up-to-date information regarding infant safe sleep, education for professionals, families, and the broader community, increasing the availability of safe sleep spaces, and the broader reduction of infant sleep related death. As has been the case in prior years, this work was critically supported and carried out through partnerships and relationships among the Oklahoma Maternal, Infant, Early Childhood Home Visiting (MIECHV) program, Oklahoma SAFE KIDS Coalition, University of Oklahoma Health Sciences’ Office of Perinatal Quality Improvement, and the Tulsa and Central Oklahoma City Fetal Infant Mortality Review (FIMR) programs.
Title V supported two programs that directly impacted infant safe sleep measures. The OSDH Infant Safe Sleep Education and Sleep Sack Hospital Partnership Program, and the Portable Crib Kit Distribution Program. There were multiple hospital partners that committed to the standards and requirements of the Cribs for Kids Hospital Certification program during this grant period. Norman Regional Healthplex achieved “gold level” status, which in addition to the “bronze level” certification they had already reached, required them to commit to distributing portable cribs to families in need, hosting community engagement and education events around infant safe sleep, and replacing their in-house use of swaddling blankets with sleep sacks to model safer alternatives to families. Bailey Medical Center and the Choctaw Nation Healthcare Center were awarded “silver level” Cribs for Kids hospital certification, which beyond the “bronze level” certification primarily adds compliance audits to the infant safe sleep practices and education, and the use of sleep sacks within the hospital in lieu of blankets to model not having loose bedding in the sleep space for parents. INTEGRIS Miami, INTEGRIS Grove, and St. Francis Hospital South were all awarded “bronze level” hospital certification. All hospitals which partner with OSDH to distribute sleep sacks and infant safe sleep education were required to apply for and maintain hospital certification at the “bronze level” from Cribs for Kids, which requires them to: implement a hospital or hospital system-wide Infant Safe Sleep Policy; promote safe sleep education on the hospital website; promote hospital-wide infant safe sleep imagery; provide safe sleep training to staff caring for infants; and, provide safe sleep education to family and caregivers of infants under one year. During the grant reporting period, 288 portable cribs were distributed to families in need.
MCH continued to partner with the Charlie’s Kids Foundation in promoting a series of co-branded educational videos on the topic of infant safe sleep such as Safe Sleep ABCs, Breastfeeding Safely During Night Feedings, Safety Risks of Co-Sleeping, and other related topics. These videos were an ideal length for sharing on social media such as Instagram and Twitter during the month of October in conjunction with SUID awareness month.
The Infant Safe Sleep Work Group co-lead conducted educational sessions on infant safe sleep with approximately 1,000 families attending a rural community baby shower and provided an interview on infant sleep safety with a local news station and radio station to raise awareness during Sudden Unexpected Infant Death (SUID) awareness month. Key partners in the two largest metropolitan areas in Oklahoma, OCCHD and THD both conducted infant safe sleep trainings and outreach events. OCCHD trained 551 participants, including those in child care licensing, child protection workers, and parents in infant safe sleep guidelines. THD held their annual North Tulsa Community Baby Shower event and provided safe sleep education to 170 people. At the Tulsa Baby Shower, 89% of caregivers knew the safest way to lay a baby down to sleep and 98% knew babies were safest in the parent’s room utilizing a separate sleep space like bassinet, crib, or pack and play. THD staff also provided infant safe sleep education to east Tulsa residents at an event with many Spanish speakers, educating approximately 100 attendees. Additionally, staff presented a pack and play demonstration and individual safe sleep education to 40-plus attendees at an annual breastfeeding reception hosted by WIC.
The SUID infant mortality rate per 1,000 births increased in the African American community to 3.5 in 2022 compared to 3.3 the prior year in 2021. In the American Indian community however, there was a decrease in 2022 to 1.8 from 2.2 the previous year. These numbers continue to show disparities against the overall SUIDs infant mortality rate which was 1.7 for 2022.
Challenges:
Several hospitals were removed from program participation after multiple years of failing to achieve the program requirements, primarily the application for and achievement of Cribs for Kids “bronze level” certification. Additionally, staff turnover at hospitals made forward momentum in engaging new partners difficult.
Regarding infants sleeping alone, during 2018-2021, the overall percentage was 54.2%, slightly less than the 55% during 2016-2019. The percentage of white infants was 57.9%, American Indian percentage much smaller at 50.2%, and African American also at lower rate of 36.4%. Co-sleeping remained a significant concern and highlights the need for more information and education.
NPM 4: A) Percent of infants who are ever breastfed and B) Percent of infants breastfed exclusively through 6 months.
Objective 1: Increase the percent of mothers who breastfeed their infants at hospital discharge from 80.4% in 2018 to 85.0% by 2025.
Objective 2: Increase the percent of mothers who exclusively breastfeed their infants through 6 months of age from 29.6% in 2016 to 35% by 2025.
Data:
In 2022, Oklahoma Vital Statistic data showed 84.5% of new mothers were breastfeeding at hospital discharge, an increase from 2020 (81.1%). The Oklahoma Toddler Survey (TOTS) provided data to monitor feeding at six months duration. According to 2018-2022 TOTS data, 47.3% of women reported breastfeeding their infants to six months of age, an increase from the 34.7% rate for 2012-2014. The National Immunization Survey (NIS) 2020 showed that 22.3% of Oklahoma mothers exclusively breastfed through six months of age. MCH monitored breastfeeding initiation, duration, and exclusivity using data from Pregnancy Risk Assessment Monitoring System (PRAMS), Women, Infants and Children Supplemental Nutrition Program (WIC), NIS, and TOTS. This information was shared with state policymakers, health care providers, families, and community groups.
Successes:
For the 11th Annual Becoming Baby-Friendly in OK (BBFOK) Summit (BBF Summit) at Metro Technology Center’s Business Center, 130 participants met with leadership teams from 16 hospitals. The attendees obtained the Continuing Education Certificate for 6.8 CNEs. Keynote speakers Sarah N. Taylor, MD, MSCR discussed “Evidence-Based Lactation Practices in the NICU: What, When, and Why?” and “Overcoming NICU Admission to Achieve the Family’s Feeding Goals”, and Jarold “Tom” Johnston, DNP, CNM, IBCLC discussed “Neonatal Abstinence Syndrome” and “The Role of the Father in Breastfeeding”. Becky Mannel, Director of OK Breastfeeding Resource Center (OBRC) began the summit by outlining Oklahoma’s Breastfeeding “State of the State”, with updates on breastfeeding and preterm infants, goals, surveys, Baby-Friendly Hospitals, Oklahoma Mothers’ Milk Bank (OMMB), articles, research and more. She closed out the BBF Summit with her session on “Lactation Care in the NICU.”
The BBF Summit included a panel discussion with professionals and impacted families entitled: “NICU Practices and Experiences.” SSM Saint Anthony Hospital in Oklahoma City was recognized for achieving redesignation, maintaining the state’s eleven designated and redesignated hospitals. Also featured were sessions on “New Oklahoma Medicaid Benefits for Improving Maternal/Child Health.”
OMMB dispensed over 143,000 ounces of pasteurized human donor milk, an 8% increase from the previous year. Efforts to recruit and serve level II NICUs and mother/baby units continued. The OMMB provided pasteurized human donor milk to 37 hospitals (22 of those were out-of-state hospitals in states without milk banks). Nine Oklahoma hospitals provided human donor milk in their mother/baby units when supplementation was medically indicated. There were 25 depots (3 out-of-state), with 9 in county health departments and 4 more pending. SoonerCare coverage of donor milk for babies at home with a medical need, expanded outpatient service, serving 36 outpatients in 2022. OMMB commissioned a local artist to design and paint a memorial wall mural for bereaved mothers who donated milk in their baby’s memory.
MCH support continued for the Oklahoma Breastfeeding Hotline (OBH), providing information and referrals for 2,061 mothers and health care providers, and for the Hospital Breastfeeding Education Program (HBEP), BBFOK, and OMMB. With texting capability, OBH was able to contact and answer questions, provide support, and/or referrals for 97% of callers. Calls and texts were received from families delivering at 26 different hospitals, representing over 59% of Oklahoma’s 44 birthing hospitals. Most contacts continued to be first-time mothers at 58% with milk production being the primary reason for contacting the hotline (18%), followed by maternal medications (12%), and engorgement/pain/mastitis (11%).
OBRC offered four one-day Making Breastfeeding Easier training courses and seven two-day Breastfeeding Basics and Beyond trainings in Oklahoma City and Tulsa in collaboration with OSDH’s home visiting programs. Additionally, OBRC provided four Making Breastfeeding Easier for NICU Families, scheduled upon hospital request. OBRC’s interactive online education format continued to include a low-cost 15-hour online training, a 3-hour online breastfeeding training and a free prenatal breastfeeding education course. Since its launch, 614 families/persons have participated in the free online prenatal course. Fourteen hospitals accessed the 15-hour online staff training, meeting Baby-Friendly USA’s didactic education requirement, and five hospitals participated in the new, interactive online 3-hour breastfeeding education course for providers. OBRC staff provided 2 hybrid -hour breastfeeding trainings for OPQIC’s Perinatal Nurses Forum bootcamp, reaching 90 nurses from Oklahoma hospitals. Clinical rotations, varying from 1-4 weeks, were provided for pediatric residents, OSDH WIC staff, and dietetic interns from OUHSC, Oklahoma State University (OSU) and University of Central Oklahoma (UCO).
Organizations, and partners, promoted the World Breastfeeding Week (WBW) theme, National Breastfeeding Month (NBM), and weekly Breastfeeding Week themes through state and community news releases, websites, social media, and WBW materials.
MCH and CAH staff regularly attended, participated in, and shared information from OK’s Legislative Diabetes Caucus meetings and activities and promoted breastfeeding duration through OPQIC and Preparing for a Lifetime meetings, and National Nutrition Month activities.
The Oklahoma WIC Program continued online certification, education appointments and sponsored the live Breastfeeding Symposium for Healthcare Providers. Sessions included Understanding Disparities and the Historical Significance of Breastfeeding Communities of Color; Trauma and Breastfeeding; Cannabis Use During Pregnancy and Breastfeeding; and Supplementation and Unique Needs for Non-Gestational Parents with 224 in attendance. WIC also hosted the Breastfeeding Educator’s Course for staff providing WIC services, led by Alabama’s Glenda Dickerson, MSN, RN, IBCLC with 108 attendees. Additionally, WIC hosted a virtual Certified Lactation Specialist (CLS) certification course facilitated by the Lactation Education Consultant (LEC) group with 35 staff in attendance. WIC’s Breastfeeding Peer Counselor Program continued in 13 counties and 26 clinic sites, with 29 Breastfeeding Peer Counselors.
COBA leadership continued to work closely with members to promote the passage of legislation, Providing Urgent Maternal Protections (PUMP) for Nursing Mothers Act. Information about the Act was presented during the Spring COBA meeting. In February, 15 members participated in an in-person advocacy event, Bagels for Breastfeeding, at the State Capitol.
COBA’s Fall Virtual Meeting, with 67 registered, focused on Maternal Health Matters with Lauri Applekamp from March of Dimes, Kate Arnold, MD, MBA from Variety Care, Cassandra Querdibitty, PhD, MPH from the Southern Plains Tribal Health Board, and Hanna Ralston of the Tulsa Birth Equity Initiative.
Another virtual webinar was featured in August for National Breastfeeding Month. Pediatrician Todd Wolynn, MD delivered “A Pediatrician’s Advice on Your Breastfeeding Journey” to 81 participants.
In September, 37 participants participated in an in-person workshop to learn “Gentle Manual Therapeutic Techniques in Lactation”.
Additionally, COBA published on their website a list of Maternal Mental Health Resources.
Challenges:
OMMB noted that some Oklahoma hospitals have decreased their usage of donor milk due to lower census in NICUs and increased operational costs (supply chain, labor costs). OBRC has been challenged to assist hospitals as they adapt to the new Baby-Friendly Hospital Initiative guidelines for Step 2 which outlines the types of education all staff and providers are to receive for the facility to become designated as Baby-Friendly. Additionally, changes in hospital priorities, such as implementing electronic documentation, have redirected efforts for several facilities. Ongoing issues were countering physician opposition and misinformation about Baby-Friendly requirements.
MCH experienced challenges related to vacant positions. The Nutrition and Lactation Coordinator went unfilled for six months from April through August 2023.
Objective 3: Increase the number of Oklahoma Breastfeeding Friendly Worksites, including schools and child care centers, from 380 sites in 2022 to 400 sites in 2025.
Data:
Oklahoma continued to recognize 380 Breastfeeding Friendly Worksites for providing outstanding support to Oklahoma mothers and their breastfeeding infants and children.
Successes:
Work groups representing a variety of partners received updates and met virtually to promote activities and worksite recognition. Partners identified areas of opportunity for program promotion. MCH, OBRC and COBA maintained an updated list of Breastfeeding Friendly Worksites on their websites.
Challenges:
Competing priorities and staff reductions made recruiting and retaining active work group members and increasing recognized breastfeeding friendly worksites challenging.
MCH experienced challenges related to the vacant Nutrition and Lactation Coordinator position from April through August 2023.
Health Equity Objective 1: Increase the percent of American Indian and Black mothers who exclusively breastfeed their infant to 8 weeks or more from 46.4% and 45.9% in 2016-2018 to 50.5% and 51.1% by 2025.
According to Pregnancy Risk Assessment data for 2018-2021, the rates for American Indian and African American mothers exclusively breastfeeding for 8 weeks or more were 47.3% and 46.9%, respectively.
Successes:
Efforts to address disparities focused on featuring communities of color in staff recruitment, training materials, and in selection of topics and speakers. The state’s multicultural population was reflected in brochures, websites, posters, PSAs and in social media posts.
COBA continued its scholarship program providing funding for lactation education and IBCLC exam fees for first time minority group candidates serving minorities or planning to work in OK underserved areas. The strategic plan focused on building a diverse board of directors, networking with partners with a shared mission, and aligning efforts with state and national lactation initiatives, while promoting education, public awareness, and advocacy for OK breastfeeding families. Work group and COBA membership included representation from communities of color and sought to increase input from a variety of ethnic and racial groups.
Challenges:
Changes in hospital priorities, such as implementing electronic documentation, have redirected efforts for several facilities and countering physician opposition and misinformation about Baby-Friendly have been ongoing issues. Competing priorities and staff reductions within work groups created challenges, including the vacant MCH position.
Hospital priorities continued to be redirected to manage the changes required to train staff and obtain supplies. COBA continued to recruit and train members and board members from diverse groups to develop leadership, communication, and financial skills to maintain and promote ongoing and new projects.
Health Access Objective 1: Develop information and guidelines for food pantries, shelters, regarding supporting breastfeeding in emergency situations.
Successes:
MCH continued to display and promote information on supporting breastfeeding in emergencies on the OSDH website, including links to the OBH and CDC’s Infant Feeding in Disasters and Emergencies websites, links to fact sheets/infographics, and links to the International Lactation Consultant Association’s (ILCA) and United States Breastfeeding Committee’s (USBC) Breastfeeding in Emergencies websites.
COBA’s website also posted Infant & Young Child Feeding During Emergencies, a position statement calling for organizations and shelters to screen families with infants and young children for their preferred feeding methods and provide lactation support empowering mothers to express breast milk (education on pumps or hand expression).
Challenges:
The MCH Nutrition and Lactation Coordinator vacancy also impacted this work.
SPM 2 Infant mortality rate per 1,000 live births
Objective 1: Screen 100% of newborns in Oklahoma and maintain timely follow-up to definitive diagnosis and clinical management for infants with positive screens.
Data:
According to the latest data available, 98.7% of babies born in Oklahoma hospitals in 2022 were screened through the Newborn Screening Program (NSP) for all disorders on the Oklahoma Newborn Screening (NBS) Panel. One hundred percent of newborns received short-term follow-up (STFU) services for diagnosis and 100% of affected newborns were referred to long-term follow-up (LTFU) for care coordination services.
For 2022, all 539 newborns with sickle cell trait and hemoglobin C trait received educational material regarding trait status and were referred for genetic counseling. Many of the families also received trait counseling from their child's primary physician, as both families and physicians on record were sent screening results. The NSP offered these families an opportunity to discuss long-term life and family planning issues with a genetic counselor. Of the 539 families, 15 received counseling with a board-certified genetic counselor. All newborns identified with an out-of-range cystic fibrosis screen were referred for genetic counseling (90 of the 96 received counseling). All cases of confirmed diagnosis for other newborn screening disorders were referred for genetic counseling and 29 received genetic counseling.
Successes:
Title V funding continued to support the newborn screening activities statewide. The NSP, housed within OSDH’s Screening and Special Services Division (SSD) continued activities to educate providers and hospitals about the need for newborn screening and procedural issues regarding collecting and submitting the specimens to the Public Health Laboratory for testing. Title V funding also supported the Oklahoma Birth Defects Registry (OBDR), an active, population-based public health surveillance system. The mission of the OBDR remained to identify opportunities to prevent, optimize early detection of birth defects, and reduce infant mortality. In addition, educational sessions were provided to county health department nurses, Children First nurses (the State’s Nurse Family Partnership program), and medical personnel about the NSP and OBDR. Additionally, education was provided at health fairs and community baby shower events across the state.
In 2023, the NSP utilized Tableau dashboards for hospital reporting. The NSP also established a hospital site visit/education plan for 2024 for all 44 birthing hospitals. Since the COVID-19 pandemic, the NSP has not been able to conduct routine site visits. Progress was made on linking NSP specimens with vital records and historical linkage is now possible. Historical linkage has occurred for newborn hearing screening.
During 2023, the NSP began transitioning long-term follow-up to include annual data submission from the specialty providers. The NSP created an annual survey utilizing REDCap. The program worked with specialty providers to determine variables to be tracked through the survey. The NSP and PHL continued the partnership with the OHA and OPQI on the quality improvement (QI) program, “Every Baby Counts”, to address delays in newborn screening. The overall goal of the program remained to improve timeliness of newborn screening through collaboration with birthing hospitals and the contracted courier service to improve transit time (time it takes for specimens to arrive at PHL from the time of collection). The QI program included virtual educational sessions for all birthing hospitals that requested additional training.
Staff from Screening and Special Services actively collaborated with MCH on several projects, including the Preparing for a Lifetime, It’s Everyone’s Responsibility infant mortality reduction initiative, OPQI and the Oklahoma FIMR projects.
The NSP continued to provide trainings on the topics of newborn screening and genetics for other statewide programs such as Children First, Healthy Start, Oklahoma Partnership for School Readiness, Oklahoma Parents as Teachers (OPAT), MIECHV, the Child Abuse Training and Coordination (CATC) Program, and the Home Visitation Leadership Advisory Council (HVLAC).
Challenges:
Challenges related to improving newborn screening timeliness included difficulty with hospital engagement due to staff turnover, as well as continued challenges from the PHL move from Oklahoma City to Stillwater during the pandemic.
An additional challenge was the inadequate number of medical specialists in the state available to serve throughout the state. Many specialty services were located only in the two large metropolitan cities, requiring families to travel long distances for appropriate care. The state also lost one of the two metabolic genetics centers in the state, leaving only one center to receive and care for all the NBS referrals.
Health Access Objective 2. Reduce the prevalence of substance-exposed newborns from 6.2 per 1,000 in 2016 to 5.0 in 2025.
According to 2021 Oklahoma hospital discharge data, 6.3 infants per 1,000 hospital births were diagnosed with neonatal abstinence syndrome in 2019, compared with 6.6 in 2020.
Successes:
According to the Oklahoma Health Care Authority State Fiscal Year 2022 Annual Report, 27,429 or 57% of all births in Oklahoma were covered by the Medicaid programs SoonerCare or Soon-To-Be-Sooners (STBS). The Medicaid program STBS continued to provide health care benefits through the state children's health insurance program for the unborn children of pregnant females who would not otherwise qualify for SoonerCare benefits due to their citizenship status and those women with incomes between 133% and 185% of Federal Poverty Level (FPL). MCH continued to have a strong partnership with staff at the Oklahoma Health Care Authority (OHCA), the state agency that administers the Medicaid program.
County health department (CHD) staff continued to assist individuals and families applying for Medicaid benefits through the online enrollment process. Eligibility was determined at the time of application and clients were immediately provided with a Medicaid ID number to use in setting up appointments with providers, which assisted pregnant females in obtaining earlier access to prenatal care.
OPQIC addressed issues identified by providers and continued to serve as the link between providers and policymakers. Priority issues this year included support for Medicaid expansion to 12 months postpartum which became effective 1/1/2023. Data is not available yet on the impact this change had on maternal health and access to care. In addition, the Maternal Health Task Force members and OPQIC members encouraged exploration of reimbursement for doulas and the continuation of SoonerPlan which is a limited benefit plan that only covers reproductive health needs.
Traditionally, as part of the MCH Comprehensive Program Reviews conducted with county health departments and routine site visits to contractors, MCH assessed community issues related to access to prenatal care. However, site visits had been suspended due to COVID-19 response activities and only resumed briefly before the loss of Title X funds. Leadership has suspended site visits and staff will have to work to develop a new quality improvement monitoring plan.
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. County health departments and contract providers were expected to keep current resource lists and to link clients with maternity providers. Nine county health departments offered maternity services this year increasing access to early prenatal care. For clients choosing to follow up with the county health department for prenatal care, the initial prenatal lab work could be drawn during the pregnancy test visit and an appointment scheduled with the APRN. During this grant year, 142 clients received prenatal care through OSDH.
With the continuation of STBS as a Medicaid option for health care coverage, many pregnant women were eligible for coverage for prenatal care and delivery that did not qualify for full Title XIX benefits. However, STBS continued to be a limited benefit package with coverage ending at delivery. Through OPQIC meetings and partnerships, it was apparent that access to care was still an issue for many women due to distance and provider availability, especially in rural areas of the state.
MCH continued to provide services in accordance with the Office of Population Affairs and the CDC’s guidelines for “Providing Quality Family Planning (QFP) Services” (4/2014). The QFP provided recommendations for evidence-based practice and encouraged health care providers to treat every visit as a preconception health visit, providing targeted preconception and interconception health counseling to every client. OSDH continued utilizing these guidelines in the provision of family planning and reproductive health care services, including preconception health care in county health departments and contractor clinics. All female clients were strongly encouraged to complete the Preconception Screening Tool to assist in identifying risk factors, provide related education on risks identified, and promote reproductive health planning. For those seeking pregnancy within the next year, counseling included the importance of early prenatal care. Screening for a history of premature birth was included in pregnancy test counseling to help educate women with a prior preterm delivery on the importance of early prenatal care.
Due to the continued high rates of opioid use and increasing rates of newborns diagnosed and treated for neonatal abstinence syndrome, the OMNO (Oklahoma Mothers and Newborns Affected by Opioids) Work Group developed a toolkit for hospitals choosing to implement the Obstetric Care for Women with Opioid Use Disorder Patient Safety bundle as part of the Alliance for Innovation on Maternal Health (AIM) Initiative. The toolkit, launched in September 2019, included prescribing guidelines, examples of universal screening tools, information on Screening, Brief Intervention and Referral to Treatment (SBIRT), information on Medication Assisted Treatment (MAT), behavioral health resources and evidence-based resources. The toolkit is available online at: https://opqic.org/omno/maternal/. The most common substances of use/abuse reported were amphetamines, cannabinoids, fentanyl, heroin, buprenorphine, and methadone.
The OSDH was awarded the five-year State Maternal Health Innovation Program (SMHIP) grant to address maternal morbidity and mortality in innovative ways in 2019. This grant, which began in October 2019, continued with projects to address the lack of access to quality prenatal care for women in ethnic and racial minorities, or tribally affiliated, and/or lived in rural areas. Additional projects included substance use/abuse in pregnant and postpartum women, maternal morbidity, and telehealth support for evidenced-based, quality obstetrical care. Contracts were maintained with Oklahoma State University (OSU) for Project ECHO, Cherokee Nation, the STAR clinic for pregnant mothers, Southern Plains Tribal Health Board (SPTHB) and CHESS Health. Through the contract with OSU, a maternal health OB ECHO (Extension for Community Healthcare Outcomes) continued bi-monthly, providing didactic information for local OB providers on high-risk conditions/management recommendations and case review with input from the team on standards of care and recommendations for quality care and referral. OSDH also contracted with Cherokee Nation to expand access to Maternal Fetal Medicine both within the Cherokee Nation health system and through telehealth visits. Another contract continued with the Oklahoma University Health Science Center Maternal Fetal Medicine STAR (Substance Use Treatment and Recovery) clinic to help cover services for pregnant women with substance use disorders. Data indicated that most mothers enrolled in this program were discharged after delivery with their infant. Through the contract with Southern Plains Tribal Health Board, culturally appropriate media messages were created to educate tribal members on maternal health issues, including preconception health care and recommendations for pregnant Native American mothers. SPTHB also continued identifying contacts for some of the smaller tribes in the state and assessing gaps in services. MCH continued a contract with CHESS Health for the e-intervention application to make a warm handoff, through the application, for pregnant women with substance use and/or mental health needs. Access to CHESS Health was available statewide for all family planning, child health and maternity clients but was not widely utilized in OSDH clinics. Efforts this year focused on educating staff again on the availability of this service and assessing barriers to utilization.
The Maternal Health Task Force continued in partnership with OPQIC through the SMHIP Grant. A strategic map (OMHTF Strategic Profile 2020-2024r.pdf (oklahoma.gov) was developed in 2020 with the goal of improving maternal health through comprehensive health care, both preventative and reactive, for women of childbearing age; including preconception, pregnancy, childbirth, postnatal and interconception care. Four priorities were identified with access to appropriate care and maternal health programs identified as priority. The Access to Care work group focused on increasing access to quality care including access to midwifery and doula care. The Health Equity Work Group focused on developing a survey to assess resources across the state for midwifery care and doula care. These groups merged for a couple meetings to start planning a combined strategy since goals for each group overlapped.
Challenges:
The STBS program, created to provide insurance coverage for women who were excluded from full Medicaid benefits due to citizenship status, continued to offer a limited benefit package, which only included prenatal care services. Insurance coverage ended at delivery hospital discharge. Several years ago, STBS changed eligibility requirements to include those similar benefits for all women between 133% and 185% FPL, regardless of citizenship status, which continued to leave a large percentage of pregnant women with limited prenatal care coverage. The legislature approved new recommendations to move the current Medicaid reimbursement system to a managed care for individuals covered under expanded Medicaid expansion. Humana, Oklahoma Complete Health, and Aetna were awarded contracts and the state will switch to these plans in April 2024.
Another major barrier to access was the continued lack of obstetric providers in the state and, consequently, transportation issues, which prevented women from accessing available care. Only 44 hospitals continued to provide delivery services in 28 of the state’s 77 counties.
With the loss of Title X Family Planning funding in April and the change in 340B eligibility, clients were rescheduled when possible or offered a prescription from a pharmacy for their contraceptives/medications until a funding solution for the program could be secured and 340B status returned. Preconception health education and early referrals to prenatal care were limited for a short time that visits were rescheduled the agency determined how to continue the provision of family planning services with state funds.
Legislation was once again introduced in the 2023 legislative session for full practice authority for advanced practice nurses. This legislation would have removed the requirement for advanced practice nurses to have a physician signature for prescriptive authority. This bill generated multiple discussions and amendments were proposed to the number of hours of practice and continuing education requirements, however, the bill was not passed. Without physicians in the rural areas, it has become increasingly difficult to find individuals to provide the signature needed for APRNs to prescribe in Oklahoma. The Oklahoma State Medical Association continued to allow practicing physicians to sign for prescriptive authority for up to six APRNs which helped alleviate the problem but is not a long-term solution. To supervise more than six, physicians had to apply, get scheduled on the agenda for an Oklahoma State Medical Association (OSMA) executive committee meeting, and attend the meeting either virtually or in-person to receive approval to sign for more than two APRNs.
Medicaid expansion was effective during this time; according to the September 2023 report, 299,572 Oklahomans were covered through the expansion. However, with the shortage of physicians in the rural areas, some enrollees were still assigned to a Primary Care Provider (PCP) in a different county. Consequently, having insurance coverage did not necessarily equate to improved access to care.
Infant Mortality Objective 1: Increase the number of delivering hospitals participating in the Period of PURPLE Crying Abusive Head Trauma curriculum from 40 in 2020 to 42 by 2025.
The number of participating hospitals was 38 as of September 30, 2023; the program lost one hospital, as they decided to implement something else for abuse prevention.
Successes:
The Injury Prevention Work Group of Preparing for a Lifetime met quarterly, virtually, to discuss projects, including the Period of PURPLE Crying (PURPLE) and the Grandparent Toolkit. PURPLE continued to provide evidence-based information via booklet, phone app, and nurse education to new parents and caregivers, all about the patterns of infant crying in an effort to reduce abusive head trauma. Hospitals had the option to request the PURPLE application in English or Spanish. DVDs were available instead of apps for those needing additional languages: Arabic, Vietnamese, Chinese, French, or Burmese.
Trainings from the National Center on Shaken Baby Syndrome were shared with the Injury Prevention Work Group and participating hospitals.
In April 2023 (Child Abuse Prevention Month) CAH staff and the Injury Prevention Work Group assisted OSDH’s Communications Department with developing a radio and video PSA on the norms of crying and the PURPLE program. These were aired in April and May of 2023. Rack cards and posters on the topic of safe sleep and infant crying were printed and distributed beginning in April 2023. Approximately 4,650 cards were distributed in English and Spanish to county health departments, hospitals, OFN, health fairs, WIC clinics, and home visitors during the grant year.
The Grandparent Toolkit Work Group included members from multiple agencies, programs, and family representatives. The work group continued to develop a grandparent-centered series of trainings and resources to aid grandparents who are either raising grandchildren or caring for grandchildren on a part-time or occasional basis. The infant health presentation includes Period of PURPLE crying and the norms of infant crying, soothing, infant safety, and safe sleep information, among other topics. The toolkit is available here: Grandparent Toolkit (oklahoma.gov)
Additionally, MCH was assigned two fully funded summer interns from the HRSA Title V MCH Internship Program. These students assisted with multiple pieces of the Grandparent Toolkit, including designing the evaluation plan, and worked with nutrition specialists at OSDH to create the nutrition trainings and resources. They filled in gaps that staff could not, and their assistance was greatly appreciated.
Challenges:
Staff time to dedicate to the grandparent project was limited, as it did not have assigned staff. A long time Injury Work Group Lead and PURPLE champion retired from state service during this time period, slowing work on training and hospital outreach.
Objective 2. Reduce the rate of fatal motor vehicle injuries in children ages 0 to 5 from 3.2 per 100,000 in 2018 to 2.9 by 2024.
Data:
Due to the small numbers of events, the rates of fatal motor vehicle injuries for children 0-5 have been calculated for a three-year period. For 2020-2022 the rate was 3.9 deaths per 100,000. This is an increase from 2.7 in the 2019-2021 period and moves us away from the goal of 2.9 set for 2024.
Successes:
The Early Childhood Coordinator (ECC), in the CAH Division of MCH, continued to provide support as a Certified Child Passenger Safety (CPS) Technician. The ECC participated in regularly scheduled car seat check-up events, assisted Safe Kids Oklahoma in teaching child passenger safety classes for parents at Variety Care Clinics that ended with a car seat check for the families, and conducted private appointments.
From October 1, 2022, through September 30, 2023, the ECC assisted Safe Kids Oklahoma with two classes for parents and car seat check-up events held at Variety Care clinics, participated in one Safe Kids Oklahoma sponsored car seat check-up event held at Garden Diggs Head Start program, and participated in four car seat check-up events held at the Piedmont Fire Department (a new monthly event sponsored by Safe Kids Oklahoma).
The ECC participated in 20 car seat checkup events held at OU Children’s Hospital in partnership with OSDH Injury Prevention Service, OU Children’s Hospital, and Safe Kids Metro, and helped two individual families at private car seat appointments.
Safe Kids Oklahoma held their Safe Kids Day at the Zoo on Saturday, May 6, 2023. Approximately 1,500 people attended the event – parents, grandparents, and children from infants through teenagers participated in the fun hands-on safety activities. The ECC, along with other MCH staff helped children play a dart ball game with different safety messages depending on the color their ball landed on. They also had car seats and booster seats on display to teach families about the importance of all children riding safely in vehicles.
MCH and Injury Prevention Service continued to team up with OU Children’s Hospital to hold car seat check-up events two days per month, and the Injury Prevention Child Passenger Safety Coordinator continued to teach the Child Passenger Safety Technician certification course to ensure that Oklahoma has CPS Technicians across the state and at most of the local county health departments.
The ECC maintained the Certified CPS Technician status and earned Continuing Education units by participating in the KIDZ in Motion Conference August 23 through 25, 2023. KIDZ in Motion is the only international conference that is focused specifically on child passenger safety, and it was held in Oklahoma City in 2023, allowing many of Oklahoma’s Certified CPS Technicians the opportunity to meet and learn from child passenger safety experts from all over the world. The Oklahoma Annual Martha Collar Tech Reunion luncheon and awards ceremony was incorporated into the KIDZ in Motion agenda.
Challenges:
The bi-monthly car seat check-up events held in collaboration with Safe Kids Metro and OU Children’s Hospital booked every available appointment slot and left some families waiting for the next event or searching for assistance elsewhere. It would be a challenge to utilize that space for an additional morning each month, and to get enough experienced CPS technicians (and interpreters) to work, but it would help meet the needs of families.
Health Equity Objective 1: Revise the Preparing for a Lifetime annual report and one pager on the initiative to educate the community and policymakers on topics impacting infant health by December 2024.
Health Equity Objective 2: Develop and implement two new marketing campaigns focused on diversity and equity in addressing infant health, including mortality and morbidity, by December 2024.
Health Equity Objective 3: Develop and implement a train the trainer program to educate 50 professionals and community liaisons on health disparities, implicit bias, and birth equity impacting infant health by December 2024.
Data:
Preparing for a Lifetime infant mortality reduction materials were revised for release in early 2024. Two marketing campaigns were also launched, aspirin therapy and Period of PURPLE Crying. Additionally, a train the trainer program was developed by the MCH Equity and Special Projects Coordinator and is currently under review.
Successes:
MCH began meetings with the OSDH Communications Department to update the Preparing for a Lifetime: It’s Everyone’s Responsibility (PFL) campaign with new media, website, fact sheets and other educational materials. The PFL campaign was centered on the small steps parents can take now to support big moments later; Improving Infant Outcomes (oklahoma.gov)
Additionally, the Institute for Perinatal Quality Improvement maternal health equity and racial disparities e-training modules were promoted to a wider audience and access was made simpler than previous years, which significantly increased the uptake of the training.
Challenges:
OSDH has been under a hiring freeze since late Spring of 2023 and MCH has been unable to replace critical personnel. Therefore, ensuring the success of media and programs and their impact on knowledge, behaviors, and actions for optimal MCH outcomes was made more difficult due to staffing and time restrictions.
Health Equity Objective 4: Implement a statewide aspirin therapy campaign, based on emerging evidence, for pregnant women and obstetric health care providers by December 2024.
Data:
OPQIC and OSDH, in conjunction with the Oklahoma Health Care Authority, and the George Kaiser Family Foundation, launched the Low Dose Aspirin Therapy campaign this year.
Successes:
During June, OSDH staff worked with Cox Media to create the social media campaign including television and radio spots. MCH added a webpage to OSDH website regarding this initiative with information about the importance of the initiative and links to the social media ads and public service announcements: Low Dose Aspirin Initiative (oklahoma.gov). OPQIC hired a Project Manager and developed a toolkit based on ACOG recommendations for the campaign which was made available on the OPQIC website at: https://opqic.org/lda/. Additional accomplishments included outreach to both providers and patient centered newsletters and development of a plan to get free, low dose aspirin to patients. OHCA agreed to include the low dose aspirin as an approved prescription for pregnant Medicaid recipients.
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