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 twenty participants attended the 10th Anniversary Annual Becoming Baby-Friendly in OK (BBFOK) Summit at MetroTech’s Springlake Campus in Oklahoma City, with leadership teams from 20 hospitals and 21 other organizations. Keynote speakers Tom Hale, PhD, RPh, Associate Dean of Research at Texas Tech University Health Sciences Center and Executive Director of the InfantRisk Center discussed “Substance Use and Breastfeeding” and “Hot Topics and New Evidence on Medications and Lactation”; and Jen Thomas, MD, MPH, IBCLC, Pediatrician, Breastfeeding Medicine Specialist, and Clinical Assistant Professor of Community and Family Medicine and Pediatrics at Medical College of Wisconsin reviewed “The Science of Supporting Exclusive Breastfeeding (EBF): Why Not Just One Bottle?” and “Tongue Ties and the Breastfeeding Infant”. Becky Mannel, MPH, IBCLC, FILCA, Director, OK Breastfeeding Resource Center (OBRC) outlined Oklahoma’s Breastfeeding “State of the State”, with updates on infant mortality and breastfeed rates, goals, surveys, Baby-Friendly Hospitals, COVID-19, Oklahoma Mothers’ Milk Bank (OMMB), articles, research and more.
The Summit included two panel discussions with professionals and breastfeeding experts: “Community Support for all Oklahoma Breastfeeding Families” and “Ask the Experts.” Duncan Regional Hospital and SSM Health St. Anthony Hospital in Shawnee were recognized as newly designated Baby-Friendly Hospitals and Cherokee Nation WW Hastings Hospital in Tahlequah received recognition as Oklahoma’s third Baby-Friendly Hospital to achieve redesignation, increasing the state’s total to eleven designated and redesignated hospitals. Also featured were sessions on “Changes in Baby-Friendly Hospital Initiative (BFHI) Guidelines” and “New Education by OBRC”.
Prior to the Summit, Coalition of Oklahoma Breastfeeding Advocates (COBA) and OMMB held a Joint Come & Go Tour and Tasting Event, “Pinot & Pints for Preemies” celebrating the opening of the new milk bank site in Garrison Tower at University of Oklahoma Health Sciences Center (OUHSC), more than doubling its previous physical space to ~ 3,300 square feet. 80 participants toured the facility and heard remarks from Dr. Jen Thomas on Exclusive Human Milk Feedings.
Celebrating its ninth anniversary, OMMB served all five level III and both level IV neonatal intensive care units (NICUs). Twenty-three depots, with eight in county health departments were maintained with 2 more pending. OMMB continued to recruit and serve rural level II NICUs and special care nurseries, and supported twelve out-of-state hospitals without milk banks. Representing babies of bereaved mothers who donated milk in their baby’s memory, the bereavement program continued, along with discussions on how to replace the memorial wall at the new location.
MCH support continued for the OBH, providing information and referrals for 2,036 mothers and health care providers, and for the Hospital Breastfeeding Education (HBEP), BBFOK, and OMMB projects. With the texting capability, the hotline was able to contact and answer questions or provide support or referrals for 98% of callers. Calls and texts were received from families delivering at 33 different hospitals, representing over 69% of Oklahoma’s 45 birthing hospitals.
Following CDC guidelines, OBRC returned to conducting most classes in-person, and continued to offer quarterly one-day Making Breastfeeding Easier trainings and quarterly two-day Breastfeeding Basics and Beyond trainings in Oklahoma City and Tulsa in collaboration with OSDH’s home visiting programs. OBRC also created a three-hour online breastfeeding education course for providers, and in response to requests, developed and launched a one day in-person course, Making Breastfeeding Easier for NICU families. Two four-hour virtual breastfeeding trainings for OPQIC’s Perinatal Nurses Forum bootcamp reached 90 nurses from statewide hospitals and one-to-four-week clinical rotations were provided for pediatric residents, OSDH WIC staff, and dietetic interns from OUHSC, University of Central Oklahoma (UCO) and Oklahoma State University (OSU). The interactive online prenatal education session (English and Spanish) was accessed by 135 families from 21 OK birthing hospitals, 15 hospitals and organizations in and outside of Oklahoma accessed the 15-hour online staff training, meeting Baby-Friendly USA’s didactic education requirement, and an interactive online three-hour breastfeeding education course for providers was launched.
MCH and Community Analysis and Linkages coordinated efforts to seek additional grant funding from the National Association of Chronic Disease Directors (NACDD) to reimburse OK birthing hospitals for Baby-Friendly redesignation and staff training fees. Work group members continued to review, update, and condense the PFL breastfeeding website pages in the revised OK state website format. Breastfeeding friendly worksites rose to 380 recognized semi-annually through meetings and websites. WIC’s Breastfeeding Task Force (WBTF) including COBA, MCH, OBRC, Indian Tribal 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 WIC also collaborated with the OK United States Department of Labor (USDOL) to co-present a USDOL webinar, Break Time for Nursing Mothers-Conversations with OK Department of Health as part of their NBM Commemoration.
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 PFL meetings, and National Nutrition Month activities. Binitha Kunnel, MS, MCH Administrative Program Manager for Assessment, in partnership with MCH and OBRC, created and shared a poster presentation, Comparison of Breastfeeding practices Among Mothers with Term and Preterm Births, at the CityMatch Leadership and MCH Epidemiology Conference in Chicago.
WIC resumed in person and 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 also hosted two additional virtual trainings facilitated by the Lactation Education Consultant (LEC) group: the Advanced Lactation Course for Board Certified Lactation Consultants (IBCLCs) and the Lactation Cram Course, a review course for staff preparing to take the IBCLC exam. WIC’s Breastfeeding Peer Counselor (BFPC) Program continued in 13 counties and 26 clinic sites, with 32 WIC BFPCs.
COBA leadership continued to work closely with the U.S. Breastfeeding Committee, Centers for Disease Control (CDC), MCH and WIC services to monitor and share COVID-19 recommendations and changes in accessing lactation support. Informative and timely monthly newsletters were posted on the COBA website, along with four additional policy positions and statements on incarcerated women and infant and young child feeding during emergencies, bringing the total to eleven. Members promoted the passage of a senate bill providing reimbursement for medically necessary pasteurized donor human milk in a home care setting and another incentivizing OK hospitals to become Baby-Friendly by increasing the Medicaid reimbursement for Medicaid babies delivered in designated facilities.
After passage of SB 121, COBA partnered with the Oklahoma Education Association (OEA) to develop, post, and distribute two sets of the Working Moms Work Toolkit and Resource Guide to each school district and OEA presidents.
COBA’s Fall Virtual Meeting with 85 registered, featured Board Member and Advisory Council introductions and a lively Q/A discussion with Stillwater Pediatrician Malinda Webb, MD, FAAP, Breastfeeding Coordinator for OK’s Chapter of American Academy of Pediatrics (AAP), moderated by MCH Equity/Special Projects Manager, Kamisha Busby, MBA, BSN, RN, CLC.
“Navigating Lactation Support in the Workplace” was the topic for COBA’s Spring Virtual Meeting and Panel Discussion. The panel featured John Carey (former OK Legislator/Author 2004 HB 2102 [Breastfeeding Anytime/Anywhere/Jury Exemption]), Michelle Browning Coughlin, JD (Founder/President MothersEsquire), and Patricia McMahon (US Equal Employment Opportunity Commission, EEOC).
Members reviewed and completely revamped COBA’s Model Hospital Infant Feeding Policy in 2022 to align with the World Health Organization’s Implementation Guidance: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services; the revised Baby-friendly Hospital Initiative; the Baby-Friendly USA Guidelines and Evaluation Criteria for Facilities Seeking Baby-Friendly Designation, Sixth Edition; and the Academy of Breastfeeding Medicine Clinical Protocol #7: Model Maternity Policy Supportive of Breastfeeding.
Challenges:
OMMB continued to maintain operations during ongoing COVID-19 disruptions although staffing was impacted at various times due to breakthrough infections of vaccinated staff. The initial BBFOK Summit date was postponed due to high COVID-19 cases. Following CDC guidelines, OBRC enacted a mandatory vaccination requirement for those attending the Summit in person. The pandemic and a shortage of nursing and lactation staff caused hospitals to reconsider the necessity of paying fees to maintain Baby-Friendly status. Hospital leadership changes derailed some existing breastfeeding task forces and required recruiting and educating new BBFOK leaders. Changes in hospital priorities, such as implementing electronic documentation, redirected efforts for several facilities. Countering physician opposition and misinformation about Baby-Friendly and exclusive breastfeeding have been ongoing issues.
Objective 3: Increase the number of Oklahoma Breastfeeding Friendly Worksites, including schools and childcare centers from 380 sites in 2022 to 400 sites in 2025.
Data:
Oklahoma’s recognized breastfeeding friendly worksites increased to 380 in 2022; 366 were Gold Star Worksites and 123 were health care facilities.
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.
Challenges:
Competing priorities and staff reductions made recruiting and retaining active work group members and increasing recognized breastfeeding friendly worksites challenging.
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 PRAMS data for 2021, the rates for American Indian and Black mothers exclusively breastfeeding for 8 weeks or more were 43.9% and 43.5%, 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. Baby-Friendly videos on the OBRC website featured stories from a Black mom and a nurse. NBM celebrations, promoted by MCH, COBA, OBRC and partners, targeted disparities and shared resources for communities of color.
COBA posted World Breastfeeding Week (WBW) and NBM messages and shared on social media its “Breastfeeding Conversations” series of five video messages relating to each week’s theme with subjects and speakers from a variety of backgrounds: OK’s Breastfeeding Friendly Worksite Initiative and Breastfeeding Dad (MCH Nutrition Consultant Nancy Bacon, MS, RDN/LD and MCH Social Work & Safe Sleep Coordinator James Craig, MSW, LCSW); Indigenous Milk Medicine Week (Kristen Arambula Hernandez, Citizen Potawatomie Nation (CPN) Birth Doula, Indigenous Breastfeeding Counselor, WIC Breastfeeding Support Group Leader, mother of two and surrogate who breastfed a friend’s adopted twins); Asian Pacific Islander Breastfeeding Week (Elizabeth Ouk, Administrative Assistant, OK Perinatal Quality Improvement Collaborative [OPQIC], mother of three); and Black Breastfeeding Week (DeAndre Opoku, MPH, Director of Health Equity and Wellness, Young Women's Christian Association [YWCA], Tulsa, mother of twins). The videos were produced by photojournalist Quin Tran Dysktra (former breastfeeding mom and KFOR-TV anchor/ reporter).
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. A new strategic plan was adopted, focusing 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:
COVID-19 continued to present challenges however staff returned to the office while continuing part-time telework and conducted both online and in person meetings and trainings. 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. OSDH employees continued to adjust to changes brought about by the move to a different location.
Health Access Objective 1: Develop information and guidelines for food pantries, shelters, regarding supporting breastfeeding in emergency situations.
Successes:
In response to the US formula shortage, COBA and WIC shared information on websites and links to a variety of state and national resources in COBA’s June newsletter including ideas for locating formula for babies and children with special nutritional needs, formula substitution lists, informal milk sharing, and professional organization statements. Information and resources were also shared with a variety of PFL workgroup members and partners for distribution to parents and families.
MCH continued to display and promote information on supporting breastfeeding in emergencies on the OSDH website including links to the OBH, the AAP 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 (ILCA) and United States Breastfeeding Committee’s (USBC) Breastfeeding in Emergencies webpages. Links to COVID-19 information and guidelines were also included on OSDH, COBA, and OBRC breastfeeding 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 nationwide formula shortage led to numerous requests for donor milk for outpatients and also media requests. OMMB Executive Director, Becky Mannel conducted over a dozen media interviews from Oklahoma, Kansas, and Missouri organizations. OMMB made it as easy as possible for a breastfeeding parent with an extra supply to donate. The response was a huge increase in breast milk donations.
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, 2021 and September 30, 2022, approximately 39,360 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 9.6% in 2022 from 10.1% in 2021. In the African-American community, the percentage of births in hospitals participating in the sleep sack program also decreased but at a smaller rate from 8.3% in 2021 to 8.1% in 2022.
The percent of infants placed to sleep on their backs was 83.6% according to 2021 PRAMS 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, and although the disparity is much smaller in the American Indian community, effort should continue to increase the percentage.
Two hospitals specifically serving American Indian families have been added since 2020. Although there are likely African-American families served in these facilities, they do not target this population.
Successes:
Partnerships continued to be a cornerstone of the successes achieved in the infant safe sleep realm in Oklahoma, with relationships among the Tulsa and Central Oklahoma City area including: Fetal Infant Mortality Review (FIMR) programs; the Oklahoma Maternal, Infant, Early Childhood Home Visiting (MIECHV) program; Oklahoma Child Death Review Board; the Oklahoma Health Care Authority; Oklahoma SAFE KIDS Coalition; and the University of Oklahoma Health Sciences’ Office of Perinatal Quality Improvement. The Infant Safe Sleep Work Group (Work Group) and its partners continued to work towards the goals of increasing infant safe sleep spaces, up-to-date infant safe sleep education among medical providers and parents, and the reduction of infant sleep-related death overall.
There are two primary programs supported by Title V with direct impact on infant safe sleep measures at the Oklahoma State Department of Health (OSDH); the Infant Safe Sleep Education and Sleep Sack Hospital Partnership program, and the Portable Crib Kit Distribution Program. Partners of the hospital sleep sack program increased their commitment to infant sleep safety through obtaining Cribs for Kids hospital certification and increased their achieved level of certification through additional requirements to reach these certifications. Hillcrest Medical Center in Tulsa 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 who were in need of one, 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. The Chickasaw Nation Medical Center, which provides labor and delivery care to the American Indian population in their area (Southcentral Oklahoma), also achieved “gold level” Cribs for Kids hospital certification in infant safe sleep during this reporting period. Duncan Regional Hospital and INTEGRIS Baptist Medical Center both achieved “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. In addition, silver level certification requires the use of sleep sacks within the hospital in lieu of blankets to model removal of having loose bedding in the sleep space environment.
The Portable Crib Kit Distribution Program continued to include crib kits with infant safe sleep education, a fitted sheet, a pacifier, an educational board book, and a sleep sack. Three hundred twenty-three portable cribs were distributed to families in need during the grant reporting period through September 30, 2022.
The Oklahoma State Department of Health also partnered with Charlie’s Kids Foundation on co-branding a series of short (around 30 seconds each) educational videos on the topics 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 promoted on social media, such as Instagram and Twitter, during month of October in conjunction with SUID awareness month.
The Work Group leaders also presented information to the Oklahoma State Legislature regarding unsafe sleep environments and the benefits of legislation banning unsafe sleep products which would reduce infant injury and death.
The Work Group co-lead conducted educational sessions on infant safe sleep with 40 families in attendance at a rural community baby shower and provided interviews on infant sleep safety with a local news station and radio stations to raise awareness during Sudden Unexpected Infant Death (SUID) awareness month. Key Partners in the two largest metropolitan areas in Oklahoma, the Oklahoma City-County Health Department (OCCHD) and Tulsa Health Department (THD) both conducted infant safe sleep trainings and outreach events. OCCHD trained 339 participants, including those in child care licensing, child protection workers, and parents throughout the reporting period in infant safe sleep guidelines. Tulsa County Health Department also held their own safe sleep educational events for teen parents, grandparents, and other caregivers, reaching a total of 361 individuals. This included a community-wide baby shower, train-the-trainer events, teen parent outreach, and other events.
During 2022, the provisional SUID infant mortality rate per 1,000 births increased in the African-American community to 3.3 compared to 3.2 in 2021. In the Native community, however, there was a decrease to 2.2 during 2022 from 2.9 in 2021. These numbers continued to show disparities against the overall SUIDs infant mortality rate which was 1.4 for 2021 and 1.8 for 2022.
For the reporting period of October 1, 2021 to September 30, 2022, the Preparing for a Lifetime Facebook page reached 587,354 individual users, 4,287 unique visits, and 88 new page likes.
Challenges:
While several additional hospitals have professed interest in becoming part of the infant safe sleep hospital sleep sack partnership, there have not been any additions to the program. Additionally, there continue to be a small number that are at risk for being removed from the program after repeated requests to come into compliance with program requirements,
Regarding infants sleeping alone, for the 2021 year (most recent data available for reporting), the overall percentage was 54%, unfortunately slightly less than the last reported data of 55% aggregated from 2016-2019. The percentage of white infants was 58%, the American Indian percentage was much smaller at 47.8%, and African American infants also saw a lower rate of 37.2%. Co-sleeping in each population is a significant ongoing concern, and speaks to the need for more information and education.
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 2021 were screened through the Newborn Screening Program (NSP) for all disorders on the Oklahoma 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 2021, all 649 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 these families an opportunity to discuss long-term life and family planning issues with a genetic counselor. Forty-six of the 649 families received counseling with a board-certified genetic counselor. All newborns identified with an out-of-range CF screen were referred for genetic counseling (93 of the 97 received counseling). All cases of confirmed diagnosis for other newborn screening disorders were referred for genetic counseling and 40 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 2022, the NSP upgraded the monthly hospital reports from a PDF report to a Tableau dashboard. Each birthing hospital was provided a minimum of two viewing licenses. Utilizing Tableau allows the birthing facilities to see current and historical reports, as well as trends over time, and eliminates the need to track a PDF copy of the report. Progress was made on linking NSP specimens with vital records. This project will continue in 2023.
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 (PHL) continued the partnership with the Oklahoma Hospital Association and OPQIC 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.
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, OPQIC 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 difficulty with hospital engagement due to COVID-19, as well as staff turnover and challenges related to the PHL move.
An additional challenge was the inadequate number of medical specialists in the state available to serve throughout the state as many specialty services were located only in the two large metropolitan cities, requiring families to travel long distances for appropriate care.
Health Access Objective 2. Reduce the prevalence of substance-exposed newborns from 6.2 per 1,000 in 2016 to 5.0 in 2025.
In 2015, Oklahoma Vital Statistics data show that 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. In 2020, first trimester care reached another high at 71.9%.
According to Oklahoma hospital discharge data, 6.6 infants per 1,000 hospital births were diagnosed with neonatal abstinence syndrome in 2020, unchanged from 6.6 in 2017.
Successes:
According to the Oklahoma Health Care Authority State Fiscal Year 2022 Annual Report, 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% 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. Priority issues this year included support for Medicaid expansion to 12 months postpartum and exploration of reimbursement for doulas.
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 OSDH staff still being reassigned to assist with COVID-19 response activities.
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. Four county health departments initiated maternity services in the spring 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. Twenty clients received prenatal care through OSDH in this grant period.
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 through the Title X grant. All female clients were strongly encouraged to complete the Women's Health Assessment Tool/Preconception 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 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 this year. Through the ten hospitals participating in this initiative, 323 mothers were identified with opioid use disorder and 313 infants ( > 35 weeks gestation) were identified with neonatal abstinence syndrome and received appropriate care.
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 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 are 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 congenital syphilis and encourage COVID-19 vaccines for pregnant Native American mothers. SPTHB continued to identify contacts for some of the smaller tribes in the state and assessing gaps in services. 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 last FFY 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 strategic map was updated last year and each work group continued to identify activities to reach the goals. The Access to Care work group focused on developing consistent, evidence-based messages for pregnant women and their families, creating a webpage on the OSDH website to host the information and finalizing recommended guidelines for the safe provision of telehealth visits. The Health Equity Work Group focused on developing a survey to assess resources across the state for midwifery care and doula care. This group also created media messages around Black Maternal Health Week, Indigenous Maternal Health Week and Midwifery Week.
Challenges:
COVID-19 continued to impact efforts this year as health care providers transitioned from pandemic to endemic roles. Some providers lifted restrictions on masks and visitors while others still maintained strict safety procedures. Providers scaled back scheduling telehealth visits as questions arose around continued reimbursement for these visits outside of emergency status. 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. The legislature approved new recommendations to move the current Medicaid reimbursement system to a managed care model after Medicaid expansion became available in July. However, the process of bidding out these services will not be completed until early 2023.
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 43 hospitals continued to provide delivery services in 28 of the state’s 77 counties.
Legislation was once again introduced in the 2022 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. 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 agreed to allow practicing physicians to sign for prescriptive authority for up to six APRNs last year which helped alleviate the problem temporarily. 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 period and over 300,000 additional Oklahomans were approved 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. 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 2023.
The number of participating hospitals was 39 as of September 30, 2022; the program neither added nor lost hospitals in FFY22.
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 new Grandparents Toolkit. 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.
The Injury Prevention Work Group partnered with the Safe Sleep Work Group to create a two-sided card and a poster in English and Spanish. The content was created to reassure parents that parenting newborns may be hard but that “You Are Not Alone.” The information presented easy to read information on infant crying and safe sleep and included the Oklahoma Parent Warmline 1-888-574-5437 for use as part of their circle of support when baby cries. The cards and posters went to the printer in September 2022.
Trainings from the National Center on Shaken Baby Syndrome were shared with the Injury Prevention Work Group and participating hospitals.
In April 2022 (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.
A Grandparent Toolkit Work Group was created by members of the Injury Prevention and Safe Sleep Work Groups. The Work Group included members from multiple agencies, programs, and family representatives. The goal was to create a grandparent-centered group of trainings and resources to aid grandparents who are either raising grandchildren or caring for grandchildren on a part-time or occasional basis. Work began on an infant care presentation during this grant period. The infant presentation includes Period of PURPLE crying and the norms of infant crying, soothing, infant safety and safe sleep information, among other topics. The Work Group sent out surveys to grandparents across the state, including grandparents raising grandchildren, to understand what topics needed to be included in the toolkit. Discipline, safe sleep, nutrition, engaging with the child, mental health, realistic expectations, healthy relationships, safety concerns, connecting with school, respite care, healthy development and teen brain health were all requested topics.
Challenges:
Staff time to dedicate to the grandparent project is limited. However, work group members are helping to divvy up tasks and lighten the load. Additionally, there were delays getting the rack cards and posters to the printer due to internal changes at OSDH. The data collection on the PURPLE apps was disrupted due to a server issue at the National Center. MCH should have data moving forward on app usage.
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 2019-2021 the rate was 2.7 child deaths per 100,000. This is a slight reduction from 2.8 in the 2018-2020 period, and exceeds the goal of 2.9 set for 2024.
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 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, 2021 through September 30, 2022, the Early Childhood Coordinator assisted Safe Kids Oklahoma with 3 classes for parents and car seat check-up events held at the Variety Care clinics, participated in 2 Safe Kids Oklahoma car seat check-up events held at Bethany Children’s Center, participated in 17 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. The Early Childhood Coordinator helped three individual families at private car seat appointments and worked the Safe Kids Oklahoma activity booth on Safe Kids Day at the Zoo May 7, 2022 – teaching families about proper car seat use as they played a learning game. The Early Childhood Coordinator also participated in the Booster Seat Bash at Crossings Community Center on August 9, 2022, teaching families about the importance of all children riding safely in vehicles, which includes younger children in car seats and school-age children in booster seats until big enough for the seatbelt to fit correctly. Safe Kids Oklahoma provided booster seats for the families that did not have one. During every car seat check and event, 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 when possible, and the Injury Prevention Child Passenger Safety Coordinator continued to teach the Child Passenger Safety Technician certification course to ensure we have CPS Technicians across the state and at most of the local county health departments.
The MCH Early Childhood Coordinator maintained the Certified CPS Technician Instructor status and earned Continuing Education units by participating in the Annual Martha Collar Tech Reunion CPST Conference in Broken Arrow, Oklahoma April 19-20, 2022.
Challenges:
During January and February of 2022, the regularly scheduled car seat check events at Oklahoma Children’s Hospital were cancelled because the new Omicron variant was spreading very quickly and the Covid-19 numbers had increased rapidly. OU Children’s Hospital had new strict guidelines for people meeting in groups during that time.
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.
Data:
Planning began for the annual report and one-pager to engage with community and professional audiences on MCH-related topics, including perinatal and infant health.
Successes:
During the reporting period of October 1, 2021, to September 30, 2022, the stakeholders and work group leads reviewed and updated the Preparing for a Lifetime toolkit and website content to ensure accurate and timely information was shared related to maternal, infant, and child health. The annual report was discussed with the groups but placed on hold to highlight our 15-year celebration in 2024. In the interim, resource cards were updated in addition to the new look of the Preparing for a Lifetime materials. Quick one-pagers on Preparing for a Lifetime, including meeting schedules, infant morbidity and mortality rates, and resources, have been updated and shared within the community and with policymakers.
Challenges:
No challenges, but decided to hold off on the development of the annual report to highlight the 15-year impact of the initiative on perinatal and infant health.
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.
Data:
Cox Media and Preparing for a Lifetime Stakeholders developed two media campaigns focused on perinatal and infant health for community and professional consumption.
Successes:
With the support of Cox Media, at least two media and marketing campaigns were created that focused on maternal and infant mortality. Topics of development consisted of infant water safety, safe sleep practices, safe sleep and breastfeeding, child health clinics, shaken baby prevention, and COVID and pregnancy. In the COVID and Pregnancy campaign, we were able to partner with a local tribal agency to obtain a family that was impacted by COVID and share their message. The campaigns created provided social media display ads, digital ads, flyers, video, and audio marketing focused on education and prevention. These media tools directed the target audience to the Preparing for a Lifetime and Child and Adolescent websites for additional information and local and national resources.
Challenges:
No challenges identified. Stakeholders and community partners were on board to make this objective a success.
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:
The train-the trainer program research and outline was completed. Identification of organization and agency champions within the Preparing for a Lifetime and Maternal Health Taskforce partnerships and completion of their enrollment within the train-to-trainer program was also accomplished.
Successes:
Between October 1, 2021, and September 30, 2022, the beginning stages of the development of the train-the-trainer training program. There were two student interns and University of North Carolina at Chapel Hill staff who assisted with research and the outline development of the training program. The outline consisted of topics including health equity, birth equity, implicit and explicit bias in maternal health, and culturally and linguistically appropriate services (CLAS) in maternal health. The train-the-trainer program consisted of four modules- two were completed, with the last two under development. Additional items to accompany the training program included a participant guide, assessment tools for agency use, and a PowerPoint presentation. The training was planned to be delivered in person or virtually for a broader reach.
Within the development of the train-the-trainer program, the Speak Up Against Racism eLearning modules were offered to clinicians, health educators, social workers, clerical, doula, midwife, and administrators who work with maternal populations within the state. There was a total of 139 learners, ranging from 104 receiving continuing education in nursing and/or medical and 35 receiving non-continuing education.
Challenges:
Staff found that there was limited information focused on the state’s needs towards addressing the training content. Research and compiling became challenging, causing the timeline of completion to be extended past the reporting period.
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