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 75.0% in 2013 to 85.0% by 2020.
 

Objective 2: Increase the percent of mothers who exclusively breastfeed their infant through 6 months of age from 21.6% in 2015 to 25.0% by 2020.
 

Data:

In 2017, Oklahoma Vital Statistic data showed that 81.3% of new mothers were breastfeeding at hospital discharge, an increase from 75.0% in 2013. The Oklahoma Toddler Survey (TOTS) provided data to monitor feeding at six months duration. According to 2014-2016 TOTS data, 41.4% 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) 2015 data showed that 21.6% 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 nineteen attended the 6th Becoming Baby-Friendly in OK (BBFOK) Summit with leadership teams from 21 hospitals and 22 organizations and seven nursing contact hours. Presenters including Becky Mannel, MPH, IBCLC, FILCA, Director, Oklahoma Breastfeeding Resource Center (OBRC) discussed the following topics: DC Breastfeeding Coalition: Reducing Disparities through Breastfeeding; Baby-Led Breastfeeding: The neurophysiologic basis for infant feeding; Business Case for Baby-Friendly Hospital Designation; The mother-baby dance: How right-brain communication supports newborn learning; Partnering for Community Transformation: Creating a Baby-Friendly District of Columbia; and State of the State/Updates: The Cost of Breastfeeding in 2018. The Summit also included a Hospital Panel: The Safety of Baby-Friendly and recognition of the May 2017 addition to Oklahoma’s list of Baby-Friendly Hospitals: Chickasaw Nation Medical Center in Ada.

 

Eight hospitals participated in monthly Baby-Friendly webinars and five continued efforts towards designation. With the addition of Hillcrest Medical Center in Tulsa in June 2018, Oklahoma’s Baby-Friendly Hospitals increased to eight. Gold Star Breastfeeding Friendly Worksites rose to 220 including 30 health care facilities recognized through meetings and websites. Nine birthing hospitals received the 2018 Oklahoma Perinatal Quality Improvement Collaborative’s (OPQIC) “Spotlight Hospital” recognition, which included BBFOK participation. Based on the August 2018 Centers for Disease Control and Prevention (CDC) Breastfeeding Rates Update, Oklahoma increased in four of five Healthy People 2020 Objectives: any breastfeeding at six and twelve months, and exclusive breastfeeding through three and six months.

 

WIC’s Breastfeeding Peer Counselor (BFPC) Program continued in 25 counties and 30 clinic sites with 45 WIC BFPCs. Three county health departments and an independent health/WIC clinic received the USDA FNS/WIC Gold Loving Support Award of Excellence for best practices beyond the core components for peer counseling.

 

WIC sponsored the Breastfeeding Educator Course for staff providing WIC services, led by Alabama’s Glenda Dickerson, MSN, RN, IBCLC, and a Regional Breastfeeding Workshop featuring national speakers was jointly offered by the Oklahoma and U.S. Lactation Consultants Associations (USLCA).

 

Coalition of Oklahoma Breastfeeding Advocates (COBA) leadership including the OBRC Director and MCH and WIC Breastfeeding Work Group leads worked to regroup following a period of transition in time to celebrate World Breastfeeding Week and National Breastfeeding Month. Three COBA members attended the US Breastfeeding Committee’s Eighth National Breastfeeding Coalitions Convening, networking with national leaders and other coalitions. Virtual Town Hall Meetings were held during August on three different days at various times to foster broad participation and gather input for activities and meetings.

 

The WIC Breastfeeding Task Force (WBTF) promoted World Breastfeeding Week (WBW), National Breastfeeding Month, and Black Breastfeeding Week (BBW) with the theme Breastfeeding – Foundation of Life through state and community news releases. WIC clinics hosted receptions, held spirit weeks, created displays, promoted Text4Baby, and shared a variety of promotional materials to support mothers and increase breastfeeding rates. MCH, WIC, and COBA promoted the theme, shared materials, and staffed displays for several La Leche League (LLL) Live, Love, and Latch events and over 200 attended Tulsa’s third annual Lift Every Baby Celebration during Black Breastfeeding Week. Norman’s mayor proclaimed August as Breastfeeding Awareness Month encouraging businesses to accommodate nursing mothers.

 

Trainings were limited due to ongoing funding issues, so the Annual WIC Breastfeeding Symposium was cancelled. However Tom Johnston, MSN, RN, APRN, CNM, IBCLC, from Fayetteville, North Carolina shared a variety of breastfeeding topics in WIC’s September RD Training (The Maternal-Newborn Microbiome, Clinical Strategies for Lactation Practice, and A Father’s Role in Breastfeeding).

 

Support continued for the Oklahoma Breastfeeding Hotline (OBH), providing information and referrals for almost 2,200 mothers, families, and health care providers, the Hospital Breastfeeding Education (HBEP) and BBFOK Projects, and the Oklahoma Mothers’ Milk Bank (OMMB). The OMMB celebrated its fifth anniversary, serving all eight level III Neonatal Intensive Care Units. Expanding to thirteen depots, OMMB continued to serve rural level II NICUs and Special Care Nurseries.

 

MCH promoted breastfeeding duration through a variety of venues; the Oklahoma Health Improvement Plan Child Health Group, OPQIC and PFL meetings, and National Nutrition Month activities. Work groups representing a variety of partners met quarterly to promote breastfeeding activities and worksite recognition. Area Coordinators in five statewide regions increased to fourteen and assisted employers in creating worksite breastfeeding policies, establishing mothers’ rooms, and receiving recognition. The addition of Breastfeeding Friendly Worksites to the Certified Healthy Oklahoma criteria has led to new worksites submitting applications, including the first applications from school districts.

 

Objective 3: Increase the percent of American Indian and Black mothers who exclusively breastfeed their infant to 8 weeks or more from 48.1% and 48.7% in 2016-2017 to 50.5% and 51.1% by 2020.

 

Data:

Data for this measure were obtained from the 2016-2017 Oklahoma PRAMS survey. Rates for American Indian and Black women continued to be significantly lower than rates for White women in the state.

 

Successes:

Efforts to address disparities focused on featuring communities of color in staff recruitment, training materials, and in selection of topics and speakers. The BBFOK Summit featured a speaker and topics addressing disparities. Several celebrations targeted and all included information for communities of color. Tulsa’s Lift Every Baby Celebration, held during WBW, was led by COBA’s previous chair; a representative of communities of color, as were many of COBA’s leadership and WIC BFPCs. Our multicultural population was reflected in brochures, websites, posters, and PSA’s.

 

The Oklahoma City COBA Baby Café reopened in September at a new location on accessible bus routes, after pausing operations in mid-April. Twice monthly drop-in cafés focused on families of color offered peer-counseling and professional lactation support along with healthy snacks and activities. COBA continued to recruit and fund training for African American facilitators to provide peer support in targeted populations with at least one reflecting the baby café’s prominent population. Communication occurred through peer counselors, social media, word of mouth, websites, birthing hospitals, health professionals, and a variety of community, professional, and social media networks.

 

Challenges:

Budget issues continued to limit trainings and attendance. Additional hospitals wanted to join the BBFOK project but were challenged to acquire and maintain physician and leadership support. Changes in hospital priorities redirected efforts in some hospitals. Competing priorities and staff reductions made recruiting and retaining active work group members difficult. The state coalition worked to regroup, recruit and train members to develop leadership, communication, and financial skills needed to maintain and promote ongoing and new projects.

 

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 22 in 2016 to 30 in 2020.

 

Objective 2. Increase the number of trainings given to providers and professional organizations on infant safe sleep from 3 in 2017 to 4 in 2018.

 

Objective 3. Increase the number of community outreach activities by Safe Sleep Work Group members from 10 in 2015 to 20 in 2020.

 

Objective 4. Increase the number of hits for the Preparing for a Lifetime website and MCH Facebook page from 411 in 2016 to 495 hits by 2020.

 

Objective 5. Increase the percent of American Indian and African American births in hospitals participating in the Safe Sleep Sack Program, from 52.6% in 2013-2014 to 60.5% in 2020.

 

Objective 6. Reduce infant mortality rate due to unsafe sleep practices for American Indian infants from 9.5 in 2014 to 7.5 by 2018 and from 14.6 in 2014 to 12.6 for African American infants by 2018.

 

Data:

Between October 1, 2017 and September 30, 2018 approximately 23,280 sleep sacks were provided to families upon discharge from the 27 participating Oklahoma birthing hospitals.

 

Infant mortality rate data are the most current available. The percent of infants who were placed to sleep on their backs was 76.1% in 2016-2017. This is a slight increase from 75.4% in 2014. However, 63.0% of African American mothers reported placing their infants to sleep on their backs, compared to 78.3% of white mothers and 79.9% of American Indian mothers.

 

Successes:

Title V continued to support the statewide initiative Preparing for a Lifetime, It’s Everyone’s Responsibility, which remained the umbrella group for a coalition of work groups focused on reducing racial disparities in infant mortality. The Safe Sleep Work Group continued to work on the goals and objectives contained in the group’s work plan. These goals met with some progress such as a rise in the number of participating Oklahoma birthing hospitals in the safe sleep sack distribution program from 25 in the beginning of October 2017 to 27 by the end of September 2018. Work Group members included representatives from the Central Oklahoma and Tulsa Fetal Infant Mortality Review (FIMR) programs, Oklahoma MIECHV, Oklahoma Child Death Review Board, Oklahoma SAFE KIDS Coalition, Oklahoma Health Care Authority, the University of Oklahoma Health Sciences’ Office of Perinatal Quality Improvement (OPQI), as well as additional community and state agencies. The OK TRAIN modules on Infant Sleep Safety: Risk Reduction and Prevention of Infant Sleep Related Deaths continued to be offered online for nurses and health professionals, early childhood professionals, and home visitors.

 

In collaboration with the OPQI and FIMR programs, additional hospitals with a high rate of African American and American Indian births were trained in infant safe sleep, implemented written safe sleep hospital policies, signed the Infant Safe Sleep Hospital Participation Agreement, and began participating in the Preparing for a Lifetime Safe Sleep Work Group’s sleep sack distribution program.

 

The Oklahoma State Department of Health (OSDH) continued a portable crib and sleep sack distribution project into its third year in FFY 2017, with sustained focus on families who were unable to provide safe sleep environments for their new infants. As the African American and American Indian families continued to be impacted the most disparately by infant mortality in Oklahoma, they remained the chief focus of the distribution effort. OSDH continued to work with the majority of the prior years’ partners: OU Children’s Hospital NICU, OSDH-contracted Home Visitation Programs, and the Oklahoma City Indian Clinic. The infant Pack-N-Plays were distributed with sleep sacks and culturally specific materials to qualified families. One hundred-sixty two cribs were distributed to families in need as of September 30, 2018.

 

The Oklahoma FIMR programs, Maternal and Child Health outreach workers in Tulsa County Health Department, and safe sleep work group co-lead provided safe sleep education in their communities, including providing updated training for home visitors, peer breastfeeding counselors, community volunteers, participants attending an African-American Men’s Health summit, allied health professionals, as well as other child care staff. Central Oklahoma FIMR provided train-the-trainer Infant Safe Sleep sessions that resulted in approximately 507 total participants from across the state.

 

Preparing for a Lifetime members continued to host community baby showers, and on September 22, 246 mothers and expectant women and men, parents, grandparents, and other caregivers were invited to attend and hear local experts present information on infant mortality, including steps everyone can take to reduce infant mortality. Some of the topics included risks for having low birth weight babies, the importance of prenatal and well-baby care, infant safe sleep, breastfeeding, and taking care of oneself during and after pregnancy. Community partners provided free door prizes and light snacks for those attending, and there were “door prizes” that included diapers, sleep sacks, and portable cribs for many of the attendees.

 

Due, at least in part, to an increase in promotional campaigns and social media postings, the Preparing for a Lifetime website saw a rise in views to 1,728 in 2018. Additionally, the Facebook page reached 2,544 individuals in 2018. OSDH added an Instagram account to its social media presence.

 

Challenges:

The large racial/ethnic disparity for both safe sleep and infant mortality in the state remained an on-going challenge. African Americans continued to have lower safe sleep (back to sleep and no bed-sharing) rates and higher infant mortality rates when compared to other races/ethnicities in the state. The American Indian community also continued to have higher rates of bed-sharing when compared to the statewide population.

 

The amount of time needed for hospital administrative staff to review safe sleep sack agreements and finalize them to begin to implement distribution of the sleep sacks to their patients continued to be considerable, and as such the approval of these changes is pending for many participating hospitals. In addition, there were several birthing hospitals that discontinued birthing services during this timeframe, resulting in reduced access to providers and facilities able to accommodate pregnant women.

 

SPM 1: Infant Mortality Rate per 1,000 live births

 

Objective 1. Reduce the rate of preterm births (births < 37 weeks gestation) from 10.8 in 2012 to 9.1 by 2020.

 

Data:

Prematurity remained the second leading cause of infant mortality in Oklahoma; rates continued the upward trend from 10.6% in 2016 to 11.1% for 2017 births. This was significantly higher than the Healthy People 2020 goal of 8.1%. Disparities remained evident with Black women having a preterm birth rate of 13.9% compared to American Indian/Alaska Natives women at 10.5%, white women at 10.1%, Hispanic women at 9.5% and Asian/Pacific Islander at 8.8%.

 

Successes:

Two work groups of the Preparing for a Lifetime, It's Everyone's Responsibility initiative addressed preconception/interconception health and prematurity in Oklahoma. The Preconception/Interconception Work Group of the Preparing for a Lifetime initiative to reduce infant mortality focused on educating women about planning for pregnancy and the importance of early and appropriate prenatal care. Work group members and county health department staff distributed preconception health information at health fairs and community baby showers across the state.

 

In October 2017, the University of North Carolina at Chapel Hill received new funding to reduce infant mortality and improve birth outcomes by advancing the status of women's preconception health particularly for low-income women and women of color in some of the country's most underserved communities. Oklahoma was chosen to participate in this funded opportunity based on work with previous CoIIN teams focused on preconception health. MCH recruited seven partners for this team: two family planning clinics, all four Oklahoma Healthy Start Projects, and a Federally Qualified Health Center (FQHC). The goal for this Preconception CoIIN team was to develop, implement, and disseminate a woman-centered, clinician-engaged, community-involved approach to the well woman visit to improve the preconception health status of women of reproductive age, particularly low-income women and women of color. After working together to identify essential components of a tool across all programs and sites, all pilot site teams met together in Oklahoma City in August 2018. Plans for the first draft and pilot of the tool were finalized through a Human Centered Design process. The first pilot phase occurred in all sites during two weeks in September 2018.

 

In May 2018, with support from CDC, the Office of Population Affairs (OPA), the Centers for Medicare and Medicaid Services (CMS), and other national partners, the Association of State and Territorial Health Officials (ASTHO), convened in Maryland state and territorial team members from the Increasing Access to Contraception Learning Community. Accomplishments of this learning community in Oklahoma included changing Oklahoma’s State Plan Amendment to remove restrictions on LARC devices for Medicaid members to support better access to LARC, a 13% increase in Nexplanon utilization and a 1.2% increase in IUD utilization by Medicaid recipients, and creation of the Focus Forward Oklahoma Program to increase access to LARCs through education and advocating for policy change. Since 2017, 15 training sessions focused on best practices in patient-centered counseling and hands-on LARC procedures skills have been hosted at no cost to the trainees. To date, 163 providers from across the state have been trained in the curriculum. OSDH clinics saw a slight increase in clients relying on Nexplanon for contraception from 10.4% to 10.6% and an increase in IUD users from 7.0% to 8.7% of clients choosing a hormonal method of contraception for calendar year 2017.

 

In 2016, the OHCA agreed to expand the preauthorization for progesterone use to include initiation between 16 and 26 weeks. OPQI staff continued sharing information about the progesterone road map “SoonerCare Guideline for Provision of Progesterone Prophylaxis of Preterm Birth” through during the Oklahoma Perinatal Quality Collaborative (OPQIC) meetings and on the Oklahoma OPQIC website. The progesterone guideline included information on patient identification, prescription initiation and patient management for progesterone use in SoonerCare women. Efforts also focused on creating awareness among women who had experienced a previous preterm birth of the potential need for progesterone therapy in subsequent pregnancies. Education was provided through NICU family support persons in the Oklahoma Family Network and counseling for women with a positive pregnancy test in OSDH clinics.

 

The Office of Perinatal Quality Improvement (OPQI) continued work on quality improvement activities with birthing hospitals, including the continued monitoring of elimination of elective, non-medically indicated inductions and scheduled cesarean sections prior to 39 weeks of gestation. The “Every Week Still Counts” initiative provided birthing hospitals with support to maintain reduced rates for elective deliveries prior to 39 weeks. Activities for the “Every Week Counts” collaborative ended 12/31/14 as hospitals transitioned to reporting these numbers to the Centers for Medicare and Medicaid Services for The Joint Commission’s PC-01 measure “Patients with elective vaginal deliveries or elective cesarean sections at > 37 weeks and < 39 weeks of gestation.” Oklahoma saw a 96% decrease from baseline data in Quarter 1, 2011 for elective scheduled deliveries prior to 39 weeks. Through Quarter 1, 2018, Oklahoma hospitals maintained an average PC-01 rate of 2% which equaled the national average.

 

The OPQIC addressed perinatal issues identified by providers and continued to serve as the link between providers and policy-makers. Information on Oklahoma Progesterone Project and cervical length measurement were placed on the OPQIC website. MCH provided funding for the OPQIC to facilitate the collaborative, including funding the OPQIC Medical Director position and MCH staff who served as members of the leadership team for the collaborative.

 

Four staff members participated in the March of Dimes, March for Babies on May 5, 2018. Information was provided on OSDH services, preconception health, safe sleep and prematurity prior to the walk around the downtown area raising awareness about premature births and the consequences of prematurity.

 

A MCH staff member joined the March of Dimes Maternal and Child Health Committee this fiscal year. This committee brought together community partners who worked together to address the following priorities: Decreasing the teen pregnancy rate in 15-19 year olds, reducing the number of women in Oklahoma with inter-pregnancy intervals less than 18 months, reaching African American and American Indian women with educational resources on 17P, promoting provider education on 17P, and increasing health literacy in women with a history of a previous preterm birth regarding the importance of progesterone therapy and early prenatal care for subsequent pregnancies. MCH Assessment staff provided updated preterm birth data for the state to assist in determining committee goals and objectives.

 

Financial support of the FIMR projects at the Tulsa Health Department (THD) and the Oklahoma City-County Health Department (OCCHD) remained a priority. Accomplishments included conducting full case reviews of fetal, neonatal and infant deaths and community action activities.

 

The Healthy Start projects in Oklahoma and Tulsa counties and the home visiting programs under the umbrella of parentPro (Maternal, Infant, and Early Childhood Home Visiting programs [MIECHIV], Children First, Parents as Teachers) received technical assistance and support from MCH. These projects and programs provided in-home support to pregnant females and their families. The Fetal and Infant Mortality Case Management project at OHCA provided phone support to decrease infant morbidity and mortality, including education on the signs and symptoms of pregnancy complications and where to seek prompt medical attention.

 

Successes included maintaining a close collaborative relationship with MCH contractors and community partners and ensuring that developed tools and information were available to health care providers across the state through the OSDH website, the OPQIC website, the OHCA website, and OPQIC quarterly meetings.

 

Challenges:

Challenges include the rising preterm birth rate at 11.1% and the inability to rise above a “D” on the March of Dimes grade card in 2018, despite all the work of OSDH and community partners. Competing priorities for hospitals and providers and implementing practice changes for reluctant physicians also created challenges to successfully reducing rates.

 

Additional issues included identifying causes of spontaneous preterm birth, especially in the African American population; a lack of education and combating misinformation regarding progesterone indications/use for women with a previous preterm delivery; differences in preauthorization and billing requirements for progesterone between insurance providers; and, identifying and addressing the impact of social and racial inequities on prematurity.

 

Objective 2. Increase the number of women who receive prenatal care in the first trimester of pregnancy from 68.5% in 2013 to 71.9% by 2020.

 

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%. The data for 2017, however, showed a rate of 69.7% which is up from the 68.3% reported in 2016.

 

According to Oklahoma hospital discharge data, 6.2 infants per 1,000 hospital births were diagnosed with neonatal abstinence syndrome in 2016, compared with 5.0 in 2014.

 

Successes:

In CY 2017, 29,031 or approximately 57.8% 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. The STBS program also continued to cover pregnant 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 to apply 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.

 

Dr. Stevens, from Warren Clinic in Tulsa, continued providing prenatal care at the Creek County Health Department.

 

CHD staff assisted clients with a positive pregnancy test in signing up for Text4Baby prior to leaving the clinic and the OHCA continued texting all women enrolled for prenatal care offering them the opportunity to enroll in Text4Baby. One of the first messages was about connecting with a prenatal care provider.

 

The OPQIC addressed issues identified by providers and continued to serve as the link between providers and policy-makers.

 

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. Clinic records were audited to ensure females with positive pregnancy tests were 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.

 

County health departments and contract providers served as safety net providers for maternity clinical services. Clinics served as the point of entry for 23,655 females for pregnancy testing and linkage with appropriate services depending on pregnancy test results. With the continuation of STBS as a Medicaid option for health care coverage, there was a decreased need for safety net providers.

 

MCH continued to promote the Office of Population Affairs and the CDC’s guidelines for “Providing Quality Family Planning Services” (4/2014). The QFP provides recommendations for evidence-based practice and encourages health care providers to treat every visit as a preconception health visit, providing targeted preconception/interconception health counseling to every client. The 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 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 is included in pregnancy test counseling to help educate women with a prior preterm delivery on the importance of early prenatal care for progesterone therapy.

 

Due to the high rates of opioid misuse and increasing rates of newborns diagnosed and treated for neonatal abstinence syndrome, work groups were established this year to identify priority activities for implementing the Obstetric Care for Women with Opioid Use Disorder Patient Safety bundle as part of the Alliance for Innovation on Maternal Health (AIM) Initiative.

 

Challenges:

The Soon-to-be-Sooners (STBS) program was created to provide insurance coverage for women who were excluded from full Medicaid benefits due to citizenship status and consequently offers a limited benefit package which only includes prenatal care services that benefit the infant. Insurance coverage for this population ends at hospital discharge. Two years ago, STBS expanded to accommodate the changes in eligibility requirements for full Medicaid benefits and covers those women between 133% and 185% FPL leaving a larger percentage of pregnant women with limited prenatal care coverage.

 

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 28 of the state’s 77 counties had hospitals providing delivery services. Since 2014, five rural hospitals have closed: Frederick, Sayre, Eufaula, Latimer County and Paul’s Valley. Last year, Memorial Hospital of Texas City stopped offering obstetric care, increasing access-to-care issues for Oklahomans in the panhandle area.

MCH staff met with community prenatal care providers in efforts to identify ways to partner and improve access to prenatal care. Due to the reduction in force in county health department staff, these conversations were put on hold.

 

Legislation was once again introduced in this legislative session for full practice authority for advanced practice nurses, however it did not pass out of committee. This legislation would have removed the requirement for advanced practice nurses to have a physician signature for prescriptive authority. Each practicing physician can only sign for two full-time APRNs creating a significant barrier to accessing services especially in rural areas of the state where there is a shortage of all health care professionals.

 

Creating new models of care is time consuming and requires legal interpretation and agency approval. Once a model of care was finally developed by clinical staff to expand access to prenatal care services in county health departments, legal review and agency reviews also took time. After the reduction in force occurred, OSDH staff were stretched too thin to add additional programs or services. All conversations regarding prenatal care expansion stopped and new innovative ideas will need to be generated when resources are available.

 

Budget shortfalls continued to impact access to care as Medicaid benefits were threatened or reduced, reimbursement remained low, physician offices closed, and rural hospitals either closed or stopped providing obstetric services.

 

Work groups also encountered the need to better define and understand the relationship of opioid use and abuse with preterm birth and neonatal abstinence syndrome.

 

Objective 3. Screen 100% of newborns in Oklahoma and maintain timely follow-up to definitive diagnosis and clinical management for infants with positive screens.

 

Data:

All newborns born in Oklahoma hospitals in 2017 (latest data available) 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 2017, all 662 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 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 49 families received counseling with a board-certified genetic counselor. All newborns identified with an out-of-range CF screen were referred for genetic counseling (67 of the 71 received counseling). All cases of confirmed diagnosis for other newborn screening disorders were referred for genetic counseling and 21 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. NSP also maintained 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.

 

Long-term follow-up activities continued to include family education, and other public and stakeholder education, such as schools and transition committees. The NSP and Public Health Laboratory continued our partnership with the Oklahoma Hospital Association to develop and implement a quality improvement program, “Every Baby Counts,” to address delays in newborn screening. The overall goal of the QI program was 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 educational Web-Ex sessions for all birthing hospitals, development and dissemination of quarterly transit time reports to birthing hospitals and expansion of courier services provided. The NSP also partnered with the Office of Perinatal Quality Improvement (OPQI) to improve transit time of newborn screening specimens and to reduce the number of unsatisfactory specimens submitted to the Public Health Laboratory (PHL).

 

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, the 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, Smart Start, 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 engagement from every birthing hospital with the QI program and identifying a champion at each facility.

 

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 4. Evaluate and (potentially) revise the Preparing for a Lifetime, It's Everyone's Responsibility statewide infant mortality reduction initiative, as it approaches its 10th year.

Data:

In 2016 the reported infant mortality rate (IMR) for Oklahoma was 7.4 with congenital malformations, low birthweight and short gestation, and sudden infant death syndrome (SIDS) being the three leading causes of death. Although a reduction has been achieved since the launch of the Preparing for a Lifetime (PFL) initiative in 2009, Oklahoma’s IMR remains above the national rate of 5.9; and racial and ethnic disparities continue to be problematic. Further, in 2016, Oklahoma ranked 42nd in infant mortality when compared to other states.

 

Progress has been made on primary measures identified for each priority area for the initiative since its inception. Data indicate improvement in nine of ten areas, with only the preterm birth rate increasing in recent years.

 

Successes:

The Preparing for a Lifetime Initiative continued to have primary partners engaged in activities. Quarterly partner meetings provided opportunities to learn more about pertinent issues, such as congenital heart defects, and share highlights of state and local level infant mortality reduction activities. Work groups addressing priority topic areas continued to promote and implement promising and evidence-based practices.

 

In September, Infant Mortality Awareness Month, current IMR and relevant outcome measures were shared during the month’s partners meeting. To recognize IM Awareness Month, various media venues were utilized to highlight progress of the Initiative as well as the work to be done to continue achieving positive outcomes. The September 2018 statewide news release illustrated the decrease in smoking rates among pregnant women in Oklahoma, noting a dramatic decline of more than 33 percent since 2009.

 

During the September 2018 PFL partners meeting, a facilitated discussion was held to gain input from partners asking how the PFL initiative could be revitalized after ten years in existence. Entitled, “the Rebirth”, partners shared thoughts and ideas, which included inviting new partners, determining new priorities as they emerge, redesigning meeting agendas, increasing outreach with relevant messages and hosting a conference in 2019. Based on input, a work plan was developed. Most notably, a Summit has been planned for September 2019. The event acknowledges the 10th anniversary of the Preparing for a Lifetime initiative with a theme of “Looking Back, Moving Forward Together” featuring three breakout tracts – clinical, community and advocacy. The goal is to host approximately 300 guests representing medical, behavioral, faith-based, tribal, state and community level individuals. The event was designed to engage participants in educational, interactive sessions which can be applied to their professional, programmatic and personal domains.

 

Challenges:

Reducing racial and ethnic disparities continued to be a primary issue of concern and challenge to improve infant and maternal outcomes for all populations. The IMR for African American infants was 13.9, more than twice that of white infants at 6.2. American Indian and Hispanic IMR also exceeded that of white infants at 12.0 and 8.3, respectively. Oklahoma has also experienced an increase among the Asian/Pacific Islander population with a 7.3 IMR. Addressing disparities remained a complicated issue involving many factors. Social and environmental dynamics, policy decisions and public systems all have implications for impacting the health and well-being of moms, infants, children and families. Through the PFL initiative, racial, ethnic and cultural issues were integrated into the work. All PFL work groups – infant safe sleep, breastfeeding, infant injury prevention, preconception/interconception care, preterm birth, maternal mood disorders, tobacco and secondhand smoke – considered, incorporated and implemented strategies to address inequity and disparity among the population we serve.

 

An additional challenge was the delay in approving the contract that provides media services for the PFL initiative, Visual Image (VI). An aspect of the “Rebirth” discussion focused on the need to promote relevant messages and educate professionals and private citizens on the PFL initiative and priority areas.

 

Organizational restructuring and staff turnover have also presented a challenge. For a time, local county health departments (CHDs) experienced a staffing shortage, particularly for nursing staff, due to the reduction in force and resignations due to the budget shortfall. As a result, CHDs have not been as actively engaged in infant mortality activities as in past years.