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 28 in 2020 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.
Objective 4: Increase the percent of American Indian and Black births in hospitals participating in the Safe Sleep Sack Program, from 73.3% in 2018 to 80% in 2022.
Objective 5: Increase the number of hospitals and other facilities serving American Indian and Black families participating in the Cribs Project, distributing pack-n-plays and safe sleep tools and education, from 5 in 2020 to 10 by 2025.
Data:
Between October 1, 2020 and September 30, 2021, approximately 37,488 sleep sacks were provided to families upon discharge from the 29 participating Oklahoma birthing hospitals. Among those participating hospitals, 62.8% of births were to American Indian women, which is a slight increase from the 2019 births. Among Black women, 86.5% gave birth in facilities participating in the sleep sack program, a decrease from 87.6% in 2019.
The percent of infants placed to sleep on their backs was 77.6% according to 2016-2019 data. This was an increase from 76.1% in 2016-2017. However, 65% of Black mothers reported placing their infants to sleep on their backs, compared to 80.1% of white mothers and 79.6% of American Indian mothers in 2016-2019.
The number of hospitals and other facilities serving American Indian and Black families has not increased since 2020. There were conversations with two birthing hospitals regarding joining the program, but due in part to internal staffing changes in these facilities, and due to the continued influence of COVID-19 on the hospital’s resources and interest in launching new projects; neither of these facilities were able to join the project.
Successes:
The alliance of partners that comprise the Infant Safe Sleep Work Group continued to be robust, with the University of Oklahoma Health Sciences’ Office of Perinatal Quality Improvement, the Oklahoma Health Care Authority, Oklahoma SAFE KIDS Coalition, Oklahoma Child Death Review Board, Oklahoma MIECHV, and representatives from the Central Oklahoma and Tulsa area Fetal Infant Mortality Review (FIMR) programs. The work group and its partners continued to work towards the goals of increasing infant safe sleep education, empowering medical providers with the most up-to-date information on infant safe sleep, and the reduction of infant sleep-related death overall.
At the Oklahoma State Department of Health (OSDH), the two largest projects related to the promotion of infant safe sleep continued to be the hospital partnerships with Oklahoma birthing hospitals in distributing sleep sacks, along with infant safe sleep education; and the partnership between the OSDH and the Oklahoma Health Care Authority on distributing portable cribs and education to families in need of a safe sleep space. The hospital safe sleep sack project saw several important partners added to the list of participating hospitals. The Cherokee Nation WW Hastings Hospital and the Choctaw Nation Healthcare Center both joined the list of hospitals distributing sleep sacks along with infant safe sleep education, and committed to engaging in these practices within their facilities. These hospital partners were especially important as they primarily served members of the tribal nations they were situated within; furthering the goal of targeting these communities, disproportionately impacted by infant safe sleep disparities. The crib kits were distributed with infant safe sleep education, a fitted sheet, a pacifier, an educational board book and a sleep sack. Two hundred and twenty-six portable cribs were distributed to families in need during the grant reporting period through September 30, 2021.
The Infant Safe Sleep Work Group co-lead conducted a train-the-trainer event with 23 rural health educators and nurses on infant safe sleep, and provided an interview on infant sleep safety with a local news station to raise awareness during Sudden Unexpected Infant Death (SUID) awareness month. Although COVID-19 response continued to be a primary focus of the public health system in Oklahoma, the Oklahoma City County Health Department (OCCHD) and Tulsa Health Department (THD) maternal outreach programs along with the Infant Safe Sleep Work Group co-lead, continued to provide safe sleep education. Central Oklahoma Fetal and Infant Mortality Review (FIMR) provided train-the-trainer Infant Safe Sleep virtual sessions that resulted in approximately 477 total participants from across the state. Due to the THD FIMR group’s re-assignments for emergency COVID-19 response until late summer 2021, they were unable to conduct the infant safe sleep training.
The racial disparity in the infant mortality rate remained but began trending smaller. For this reporting period, the infant mortality rate disparity was improved with the White Infant Mortality Rate at 0.7, Black at 1.5, and American Indian rate at 1.6.
Due, at least in part, to an increase in promotional campaigns and social media postings, the Preparing for a Lifetime Facebook page saw a significant gain in the numbers reached; 8,179 individuals from October 1, 2020 to September 30, 2021, compared to 2,975 for the previous fiscal year.
Challenges:
While there was success in adding additional partners to the infant sleep sack distribution project, the hope that the portable crib distribution project could add partners did not come to fruition. Hospital partnerships were particularly difficult to originate due to COVID-19 overwhelming resources and personnel.
One of the primary components for hospital partners that joined the OSDH sleep sack distribution program was becoming certified through Cribs for Kids as a safe sleep bronze, silver, or gold level hospital. Certification remained important because it showed a commitment to (at a minimum) a hospital or system-wide Infant Safe Sleep Policy, ensured that staff were trained in infant safe sleep, and provided safe sleep education to family/caregivers of infants less than one-year-old. This process was placed “on hold” for all partners due to the continued overwhelming need to respond to COVID-19.
The most recent data on percentage of infants sleeping alone was not as high as prior years, with the overall percentage being 55%, Non-Hispanic White at 59.8%, Non-Hispanic American Indian 50.4%, and Non-Hispanic Black infants at 35.8%. The percentage of black infants sleeping alone is especially concerning.
Although there was a small increase from the prior year, broadly there continued to be a lesser amount of crib kit distributions during this period than in prior years. At least part of the source for this reduction was fewer home visitors engaging with families due to modified COVID-19 home visiting protocols.
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 infant at hospital discharge from 80.4% in 2018 to 85.0% by 2025.
Objective 2: Increase the percent of mothers who exclusively breastfeed their infant through 6 months of age from 29.6% in 2016 to 35% by 2025.
Data:
In 2020, Oklahoma Vital Statistic data showed 81.1% of new mothers were breastfeeding at hospital discharge, a slight increase from 2018 (80.4%). The Oklahoma Toddler Survey (TOTS) provided data to monitor feeding at six months duration. According to 2018-2019 TOTS data, 46.4% of women reported breastfeeding their infants to six months of age, an increase from the 34.7% rate for 2012-2014. National Immunization Survey (NIS) 2018 data showed that 24.7% of Oklahoma mothers exclusively breastfed through six months of age. Maternal and Child Health Service (MCH) monitored breastfeeding initiation, duration, and exclusivity using 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:
One hundred eighty-five participants attended the 9th Annual Becoming Baby-Friendly in OK (BBFOK) Summit, a virtual Summit due to the COVID-19 pandemic, with leadership teams from 21 hospitals and 76 other organizations. Keynote speaker Jane Morton, MD, First Droplets Founder and former Director of Breastfeeding Medicine Program at Stanford Medical Center discussed “A Mother-centric Approach to Reduce Early Breastfeeding Cessation” in two sessions and Becky Mannel, Director, OK Breastfeeding Resource Center (OBRC) outlined “Oklahoma’s State of the State – Unprecedented”.
The Summit included two panel discussions with professionals and breastfeeding moms: “Systemic Racism and Health Disparities in Oklahoma and their Impact on Breastfeeding” and “Mothers’ Stories: Support is Critical”. Comanche County Memorial Hospital received recognition as Oklahoma’s second baby-friendly hospital to achieve redesignation, maintaining the state’s total of ten designated and redesignated hospitals in the midst of numerous hospital and statewide changes due to COVID-19. Also featured, sessions on “Full Breasts, Empty Arms: Perinatal/Infant Loss & Lactation” and “Maternal Mental Health & Breastfeeding: Perinatal Mood and Anxiety Disorders and their Impacts”.
Interspersed throughout the day were short informational videos from Community and State Partners: Coalition of Oklahoma Breastfeeding Advocates (COBA), Oklahoma Mothers’ Milk Bank (OMMB), OK Perinatal Quality Improvement Collaborative (OPQIC), Oklahoma Breastfeeding Hotline (OBH), OU Health Physicians Breastfeeding Clinic, OK WIC, and PSAs from eight Preparing for a Lifetime (PFL) Infant Mortality Reduction Initiative Work Groups.
Due to the ongoing pandemic, in-person trainings, conferences and hospital assessments were cancelled, postponed, or moved to a virtual format. MCH worked with OBRC and WIC to ensure updated Oklahoma, national, and world health resources were posted to appropriate websites.
Links to OBRC’s free interactive online prenatal education modules (in English and Spanish) were shared widely with the public and OBRC contacts including OUHSC departments of OB/GYN, Pediatrics and Family Medicine and OBRC’s Lactation Clinic as well as Oklahoma hospitals and WIC, all who shared same online modules with their prenatal clients. OBRC communicated with 35 delivering hospitals to determine their interest in joining BBFOK and/or implementing some of the Ten Steps to Successful Breastfeeding. In addition, they joined a nationwide collaborative of other state programs who are also attempting to get more hospitals to work toward Baby-Friendly designation.
Work group members continued to review, update, and condense the PFL breastfeeding website pages in the revised OK state website format, and updated the Nursing Your Newborn Fact Sheet. Breastfeeding friendly worksites rose to 367 recognized semi-annually through meetings and websites. WIC’s Breastfeeding Task Force (WBTF) including MCH, OBRC, COBA, Indian Tribal Organizations, and partners, promoted the World Breastfeeding Week (WBW) theme, National Breastfeeding Month (NBM), and Black Breastfeeding Week (BBW) through state and community news releases, websites, and social media and WBW materials. WIC continued online applications and education and sponsored the Virtual Breastfeeding Educator Course for staff providing WIC services, led by Alabama’s Glenda Dickerson, MSN, RN, IBCLC. WIC’s Breastfeeding Peer Counselor (BFPC) Program continued in 14 counties and 27 clinic sites, with 31 WIC BFPCs.
COBA leadership worked closely with the U.S. Breastfeeding Committee, Centers for Disease Control, MCH and WIC services to monitor and share COVID-19 recommendations and changes in accessing lactation support. Four additional policy positions and statements on current affairs and existing laws and policies hindering support efforts were developed and posted, bringing the total to seven. Members promoted the passage of a senate bill requiring school districts to provide lactating employees paid breaks and a private, secure, sanitary location to express milk or breastfeed a child.
MCH support continued for OBH, providing information and referrals for 2,116 mothers and health care providers, and for the Hospital Breastfeeding Education (HBEP), BBFOK, and OMMB projects. Since the launch of the texting capability, allowing users to text hotline IBCLCs, call volume has increased 20%. Calls and texts were received from families delivering at 31 different hospitals, representing over 66% of Oklahoma’s 47 birthing hospitals.
OMMB maintained operations during the ongoing pandemic with staggered staffing and continued to screen donors, pick up raw milk, pasteurize and dispense. Some staff teleworked when possible and donor recruitment and involvement actually increased!
Celebrating its eighth anniversary, OMMB served all five level III and both level IV neonatal intensive care units (NICUs). Twenty-one depots, with seven in-county health departments, were maintained, and OMMB continued to recruit and serve rural level II NICUs and special care nurseries, and supported seven out-of-state hospitals without milk banks and two other milk banks with shortages. The bereavement program continued with over 100 plaques representing babies of bereaved mothers who donated milk in their baby’s memory. OMMB contracted with University Hospitals Authority and Trust and sought funds to renovate space in Garrison Tower to expand operations and double the physical space, and promoted legislation to provide Medicaid coverage of donor milk for babies in the community with a medical need.
MCH promoted breastfeeding duration through OPQIC and PFL meetings, and National Nutrition Month activities. Work groups representing a variety of partners received updates and met virtually to promote activities and worksite recognition. MCH continued to share on its website the Breastfeeding Support Fact Sheet, which included Oklahoma’s breastfeeding rates and Maternity Practices in Infant Nutrition and Care (mPINC) Surveys, key outcomes, and activities; all helpful information for legislators, health care providers, students, advocates, and funders. Based on the August CDC Breastfeeding Rates Update, Oklahoma increased in every category.
Challenges:
Due to physician opposition, Integris Edmond Health decided not to re-designate. OBRC staff successfully converted interactive, in-person trainings to virtual trainings; however, this required more staff time and additional expertise to develop and manage polls, break out rooms, and the chat box while conducting trainings.
Objective 3: Increase the number of breastfeeding friendly worksites, including schools and childcare centers from 355 sites in 2020 to 365 sites in 2021.
Data:
Oklahoma recognized breastfeeding friendly hospitals increased to 367 in 2021. One hundred and eighteen of those were health care facilities and 280 were Gold Star Worksites.
Successes:
Work groups representing a variety of partners received updates and met virtually to promote activities and worksite recognition. Thirteen area coordinators in five statewide regions were available to assist employers to develop policies, establish mothers’ rooms, and receive recognition. MCH continued to share on its website the Breastfeeding Support Fact Sheet, including Oklahoma’s breastfeeding rates and Maternity Practices in Infant Nutrition and Care (mPINC) surveys, key outcomes and activities; all helpful information for legislators, health care providers, students, advocates, and funders. Based on the August CDC breastfeeding rates update, Oklahoma increased in every category.
Challenges:
Competing priorities and staff reductions made recruiting and retaining active work group members and efforts to increase recognized breastfeeding friendly worksites challenging.
Objective 4: 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.
Objective 5: Increase partners for outreach to ethnically diverse populations from 37.5% to 44.4% in 2021.
Data:
According to Pregnancy Risk Assessment data for 2016-2019, the rates for Black and American Indian mothers exclusively breastfeeding for 8 weeks or more were 46.9% and 48.2%, respectively. Individual year data for 2020 was not available due to not meeting the response threshold for weighting.
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. Two Baby-Friendly videos featured stories from a Black mom and a nurse and were shared on the OBRC website. NBM celebrations targeted disparities and shared resources for communities of color. Tulsa’s BBW’s online celebration was led by a former COBA chair representing communities of color. For The Village, Inc., a nonprofit formed to improve maternal and infant outcomes in the Black community by raising awareness, developing Black birth workers, and providing birth services, continued activities. Work group and COBA membership included representation from communities of color and sought to increase input from a variety of ethnic and racial groups. MCH, COBA members and partners promoted Black Maternal Health Week during April 11-17.
COBA’s virtual annual meeting featured a panel discussion, Systemic Racism and its Effects on Health Disparities in Oklahoma that included Noor Jihan Abdul-Haqq, MD, Peace of Mind Pediatrics; Maggie Green, LCSW, Greenwercs Coaching Counseling Consulting Services; and Jillian Whitaker, Better Black News. This panel discussion was again presented at the BBFOK Summit. How Good Policy Can Change Health Outcomes was the topic for COBA’s Spring Virtual Meeting’s panel discussion and included Oklahoma legislators, Senator Carri Hicks (OKC), Representative John Waldron (Tulsa) and Senator Jessica Garvin (Duncan).
Challenges:
COVID-19 continued to present many challenges. Staff teleworked, conducted online meetings, and developed virtual webinars and trainings. Hospital priorities were redirected to manage the changes required to train staff, obtain supplies, and care for COVID-19 patients, so many were unable to join or participate in the BBFOK project. MCH staff continued to operate the COVID-19 Hotline, answering questions and referring callers to available resources and services. Competing priorities and staff reductions made recruiting and retaining active work group members challenging. COBA continued to recruit and train members to develop leadership, communication, and financial skills to maintain and promote ongoing and new projects. OSDH employees continued to adjust to the many changes brought about by the move to a different location while the pandemic continued.
Objective 6: Develop information and guidelines for food pantries and shelters, regarding supporting breastfeeding in emergency situations.
Successes:
MCH shared information on supporting breastfeeding in emergencies on the OSDH website including links to the OBH, the American Academy of Pediatrics and CDC’s Infant Feeding in Disasters and Emergencies websites with links to fact sheets/infographics, as well as, links to the International Lactation Consultant Association’s and United States Breastfeeding Committee’s Breastfeeding in Emergencies webpages. Links to COVID-19 information and guidelines were also included on OSDH, COBA, and OBRC breastfeeding websites.
COBA members developed, promoted, and posted on the website a position statement on Infant & Young Child Feeding During Emergencies, calling for organizations and shelters to screen families with infants and young children for their preferred feeding methods. The statement included providing lactation support if needed, such as alternate methods of milk removal (pumps or education on methods of hand expression to empower mothers to express breast milk).
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, all newborns born in Oklahoma hospitals in 2020 were screened through the Newborn Screening Program (NSP) for the disorders of phenylketonuria (PKU) and other amino acid disorders; congenital hypothyroidism; galactosemia; sickle cell disease; other hemoglobinopathies; cystic fibrosis (CF); congenital adrenal hyperplasia; medium chain acyl-CoA dehydrogenase deficiency (MCAD) and other fatty acid disorders; organic acid disorders; biotinidase deficiency; and severe combined immunodeficiency (SCID). 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 2020, all 609 newborns with sickle cell trait and hemoglobin C trait received educational material regarding trait status and referred for genetic counseling. Many of the families also received trait counseling from their child's primary physician when seen for well child visits, as both families and physicians on record were sent screening results. The NSP offered families an opportunity to discuss long-term life and family planning issues with a genetic counselor and 41 families received counseling with a board-certified genetic counselor. All newborns identified with an out-of-range CF screen were referred for genetic counseling (71 of the 74 received counseling). All cases of confirmed diagnosis for other newborn screening disorders were referred for genetic counseling and 18 received genetic counseling.
Successes:
Title V funding continued to support the newborn screening activities statewide. The NSP, housed within the Screening and Special Services Division of the OSDH, 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 2021, the NSP added four core conditions (Mucopolysaccharidosis Type 1 (MPS 1), Pompe, Spinal Muscular Atrophy (SMA), and X-Linked Adrenoleukodystrophy (X-ALD) that were legislatively approved in 2020.
Long-term follow-up activities continued to include family education and other public and stakeholder education, such as schools and transition committees. LTFU was expanded to include a second genetics clinic in OKC. The NSP and Public Health Laboratory (PHL) continued the partnership with the Oklahoma Hospital Association and OPQI on the quality improvement program, “Every Baby Counts”, to address delays in newborn screening. The overall goal of the QI program remained to improve timeliness of newborn screening through collaboration with birthing hospitals and the contracted courier service to improve transit time (the time it takes for specimens to arrive at the PHL from the time of collection). The QI program included providing virtual educational sessions for all birthing hospitals that requested additional training. Due to staff changes and challenges with the public health lab move to Stillwater, monthly hospital reporting did not continue in 2021. During the time that the NSP was unable to provide monthly reports to facilities, staff worked on developing a Tableau dashboard so that hospitals would have access to retrieve their monthly reports.
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 Fetal and Infant Mortality Review (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), the Maternal, Infant, Early Childhood Home Visiting (MIECHV) program, 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 staff being diverted to the COVID-19 response, difficulty with hospital engagement due to COVID-19, as well as staff turnover and challenges related to the PHL move.
Capacity, an additional challenge related to the number of medical specialists in the state, remained inadequate to serve the population of the state as many specialty services were located only in the two large metropolitan cities, requiring families to travel long distances for appropriate care. Another challenge included linking to birth certificate data to capture home births for screening and follow-up activities.
Objective 3. Reduce the prevalence of substance-exposed newborns.
Data:
In 2015, the number of births to Oklahoma females who began prenatal care during the first trimester of pregnancy reached a high of 70.2% then dipped in 2016 and 2017. 2018 data indicated prenatal care in the first trimester was on the rise again and according to most recent data available, in 2020 reached another high at 70.9%.
According to 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 2017.
Successes:
According to the Oklahoma Health Care Authority State Fiscal Year 2020 Annual Report (latest report available), 27,828 deliveries or 57.4% of all births in Oklahoma were paid for 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% of Federal Poverty Level (FPL) and 185% 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 policy-makers.
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, no site visits were completed this year due to COVID-19. 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.
CHDs and contract providers served as safety net providers for maternity clinical services. 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. However, STBS continued to be a limited benefit package. 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 promote 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 through the Title X grant. All female clients were strongly encouraged to complete the Women's Health Assessment Tool/Client Engagement 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 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 was established. Opioid prescribing guidelines for pregnant and postpartum women were developed and distributed to family practice, obstetric, and pediatric health care providers. The guidelines were made available online at: https://opqic.org/omno/maternal/. A toolkit was developed 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 the 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. Activities were suspended for a few months due to competing priorities for hospital staff dealing with COVID-19. Once normal activities began resuming, 10 hospitals began reporting data. The most common substances of use/abuse reported were amphetamines, cannabinoids, 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 linkages to high-risk obstetrical care. Contracts were maintained with Oklahoma State University (OSU) for the Project ECHO, Cherokee Nation, the STAR clinic, Southern Plains Tribal Health Board and CHESS Health. Through the contract with OSU, a High-Risk OB ECHO (Extension for Community Healthcare Outcomes) continued monthly, providing didactic information for local OB providers on high-risk conditions and case review with input from the hub 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 clinic to expand services for pregnant women with substance use disorders. Data indicated that most mothers enrolled in this program are discharged after delivery with their infant. Through the contract with Southern Plains Tribal Health Board, media messages began to be updated, making them more culturally appropriate and inviting for the Native American population. SPTHB also conducted a survey to assess resources and gaps in services and identify contacts for some of the smaller tribes in the state. MCH also 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 expanded statewide this FFY for all family planning, child health and maternity clients.
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 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 strategic map was updated this year and each work group identified activities to reach the goals. The Access to Care work group focused on developing consistent, evidence-based messages for pregnant women and their families and expanding access to care through the development of recommended guidelines for the safe provision of telehealth visits.
Challenges:
The biggest challenge this year continued to be the impact of COVID-19 on access to in-person health care visits, restriction of family members from health care visits with pregnant women. Some providers lifted restrictions on masks and visitors while many maintained strict safety procedures. Telehealth visits were established with some providers, however, access to telehealth visits in rural areas of the state without quality wireless connections continued to provide 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. Four 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. Plans were on the table to move the current Medicaid reimbursement system to a managed care model as Medicaid expansion became available in July. However, it was determined that this plan was in not accordance with state statutes and the plan was dropped. Prior to this, MCH staff had met with the managed care leadership in relation to quality improvement options for access to care for pregnant women.
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 46 hospitals continued to provide delivery services in 28 of the state’s 77 counties.
Legislation was once again introduced in the 2021 legislative session for full practice authority for advanced practice nurses, however, legislative leadership refused to hear any legislation on this topic. This legislation would have removed the requirement for advanced practice nurses to have a physician signature for prescriptive authority. Each practicing physician could only sign for two full-time APRNs creating a significant barrier to accessing services especially in rural areas of the state. This year, the Oklahoma State Medical Association agreed to allow practicing physicians to sign for prescriptive authority for up to six APRNs. 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 additional APRNs.
Medicaid expansion became effective during this time period and many people signed up for coverage, however with the shortage of physicians in the rural areas, some new enrollees were assigned to a Primary Care Provider (PCP) in a different county.
Infant Mortality Objective 1: Increase the number of delivering hospitals participating in the Period of PURPLE Crying Abusive Head Trauma curriculum from 39 in 2015 to 42 by 2022.
Data:
The number of participating hospitals was 39 as of September 30, 2021; the program neither added nor lost hospitals in FFY21.
Successes:
The Injury Prevention Work Group of Preparing for a Lifetime met quarterly, virtually, to discuss projects, including the Period of PURPLE Crying (PURPLE). PURPLE continued to provide evidence-based information via booklet, DVD or 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 and DVD in English or Spanish. For those needing additional languages: Arabic, Vietnamese, Chinese, French or Burmese, only DVDs were available.
During this time, virtual presentations were given by OSDH staff and partners on PURPLE Abusive Head Trauma (AHT) and the crying curve. Presentations were made to state social workers, the state’s Head Start Health Managers, the Southern Plains Inter-Tribal Health Board’s annual conference, and staff and program managers at The Parent Child Center of Tulsa and OSDH.
COVID-19 put a hard stop on any in-person trainings or presentations. The barbershop project in Tulsa had to pause due to COVID protocols. When possible virtually, community groups in the Tulsa area were provided information via The Parent Child Center, a member of the Injury Prevention Work Group and partner in the PURPLE program.
During the spring 2021 semester, the Injury Prevention Work Group hosted an intern, who developed a practicum project around PURPLE implementation in the state. She performed an environmental scan, conducted a survey and several in-depth interviews with key personnel to better understand the barriers and benefits of the current project. Training and process improvements were also identified and shared with the Injury Prevention Work Group and the National Center on Shaken Baby Syndrome.
In April 2021 (Child Abuse Prevention Month) Child and Adolescent Health (CAH) staff and the Injury Prevention Work Group assisted MCH’s media contractor with developing a series of web and streaming ads on the norms of crying and the PURPLE program.
Injury Prevention Work Group members provided consultation with a contractor from the Hawaii Department of Health interested in the statewide approach of the work group.
The Dad postcard, created in 2019, was updated with the new statewide toll-free Child Warm Line information, available to families across the state. Additionally, the website for the Injury Prevention Work Group was updated.
Challenges:
PURPLE program participation looked a little different for much of 2021 due to COVID-19. Most mothers were allowed only one support person in the delivery room; hence, the mother and her partner were often the only recipients of the information. In some hospitals, due to COVID-19 rules, education was provided in take-home packets and not face-to-face; which is not best practice for PURPLE. These challenges do not even touch on the hardship some new parents faced, as they dealt with situations where they could not call upon grandparents and extended family to provide respite care and support.
Infant Mortality Objective 2. Reduce nonfatal motor vehicle injuries in children ages 0 to 19 from 321 in 2016 to 230 by 2025.
Data:
Due to the availability of data as reported by OSDH Injury Prevention, the data for this Objective is described in rates instead of by number. The rate of hospitalizations for nonfatal motor vehicle injuries for children ages 0-14 years in 2019 of 10.6 hospitalizations per 100,000 population was a decrease from 19.8 in 2010. Similarly, the rate of hospitalizations for nonfatal motor vehicle injuries for children ages 15-19 years in 2018 of 5.8 hospitalizations per 100,000 population was a decrease from 105.9 in 2010. Although the change over time, for both age groups, appears statistically significant, due to coding changes from the ICD-9-CM to the ICD-10-C, changes in rates should be interpreted with caution.
Successes:
The Early Childhood Coordinator, in the CAH Division of MCH, continued to provide support as a Certified Child Passenger Safety (CPS) Technician and Instructor. The Early Childhood Coordinator participated in regularly-scheduled car seat check-up events, assisted Safe Kids Oklahoma in teaching a short child passenger safety class for parents at Variety Care Clinics that ended with a car seat check for the families, and conducted a few private appointments.
From October 1, 2020 through September 30, 2021, the Early Childhood Coordinator assisted Safe Kids Oklahoma with four classes for parents and car seat check-up events held at the Variety Care clinics, and participated in 28 car seat check-up events held at OU Children’s Hospital in a partnership with OSDH Injury Prevention Service, OU Children’s Hospital, and Safe Kids Metro. The Early Childhood Coordinator also helped five individual families at private car seat appointments. During every car seat check, parents were educated about the dangers of backing over children and leaving children in hot cars.
MCH and Injury Prevention Service continued to team up with OU Children’s Hospital to hold car seat check-up events two times per month, with the CPS technicians and families following COVID-19 Safety Protocols:
- All persons (CPS Technicians, volunteers, and family members) must wear a mask.
- Driver and passengers must remain in the vehicle until called to the inspection station.
- Drivers and passengers will exit the vehicle only at inspection and practice social distancing guidelines.
When possible, family members learned how to install the car seats outside in a practice seat. The family members then installed the car seats into their own vehicles with supervision from the CPS technicians.
The MCH Early Childhood Coordinator maintained the Certified CPS Technician Instructor status and earned Continuing Education units by participating in the virtual 14th Annual Martha Collar Tech Reunion CPST Conference April 21, 2021.
Challenges:
Due to some of the restrictions caused by COVID-19 and the increase in COVID-19 cases, proper car seat installation by a certified CPS Technician was lower than desired across the state for families qualified to receive car seats and in need of assistance.
Data:
Stakeholders completed a review of areas impacting infant mortality and compared it with recent state data to establish the efficacy of the initiative’s focus.
Successes:
Current statewide data was presented at the Stakeholders’ quarterly meeting, and new initiatives from the work groups were developed. The creation and production of various media campaigns provided a platform of diversity and inclusion among birthing families, offering more opportunities to extend education and access to services. The overall IMR decreased over the past few years, to the lowest it has been since the 1980s.
Challenges:
The impact of state programming under the Preparing for a Lifetime initiative was effective, but the challenge remained that Oklahoma continued to rank higher than many other states, ranking 42nd highest out of 50, for IMR. A racial disparity between Blacks and Hispanics (when compared to the white population) continued in the state.
Data:
The goal of increasing stakeholders was placed on hold due to the COVID-19 response and the virtual nature of the quarterly meetings.
Successes:
Stakeholders were able to participate in work group meetings and stakeholder meetings via Microsoft Teams and Zoom. This provided more engagement of current stakeholders regarding participation.
Challenges:
Because the meetings were virtual, engaging nontraditional partners in innovative and interactive ways was a challenge.
Data:
Stakeholders and agency leads were able to complete a minimum of three community and professional engagements on MCH-related topics, including perinatal and infant health.
Successes:
Presentations were offered during 2021 Black Maternal Health Week addressing perinatal and infant health; a presentation for college students was completed via Zoom, and an e-Learning program was offered to address implicit bias and racial disparities.
Challenges:
Due to COVID-19, the opportunity to present at perinatal and infant health conferences was minimal.
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