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 81.3% in 2017 to 84.0% 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% by 2020.

 

Data:

In 2018, Oklahoma Vital Statistic data showed 80.4% of new mothers were breastfeeding at hospital discharge, an increase from 75.0% in 2013, but a slight decrease from 2017 (81.3%). 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) 2016 data showed that 29.6% of Oklahoma mothers exclusively breastfed through six months of age, exceeding the goal for 2020. 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-five participants attended the 8th Annual Becoming Baby-Friendly in OK (BBFOK) Summit with leadership teams from 20 hospitals and 26 organizations. Presenters Kimberly Seals-Allers, SHIFT Strategic Communications; Trish MacEnroe, Baby-Friendly USA; and Becky Mannel, OK Breastfeeding Resource Center (OBRC) discussed: Fact vs. Fibs - Countering Misinformation and Fear-Based Campaigns; Communities Matter - Effective Engagement Strategies to Build Supportive Communities; Baby-Friendly USA - Revisions to the Guidelines and Evaluation Criteria; Safe Implementation of Baby-Friendly Practices; and Breastfeeding State of the State.

 

The Summit included a Baby-Friendly Panel discussion with professionals and recognition of Oklahoma’s newest Baby Friendly Hospital, The Children’s Hospital at OU Medicine, bringing the state’s total to ten. An update on OK’s Breastfeeding Hotline (OBH) and online trainings closed the Summit. The evening before, Ms. Seals-Allers spoke with a group of advocates at the OK Mothers’ Milk Bank (OMMB), followed by a fundraising reception.

 

Due to the pandemic, in-person trainings and conferences were cancelled or postponed. MCH worked with OBRC and WIC to ensure updated Oklahoma, national, and World Health resources were posted to appropriate websites. One hundred and seventy-seven individuals attended an OBRC webinar featuring COVID-19 Breastfeeding Recommendations. Panelists included Kate Arnold, MD, OB/GYN, Variety Care; Doug Drevets, MD, University of OK Health Sciences Center (OUHSC); Malinda Webb, MD, Stillwater Medical Center/Breastfeeding Coordinator, OK Chapter American Academy of Pediatrics; and Rebecca Mannel, OBRC Director and OMMB Executive Director.

 

Responding to requests to provide online patient education, OBRC created and posted free prenatal breastfeeding education modules in English and Spanish, which were shared in meetings, newsletters, websites, and social media. Hospitals and WIC provided the links to clients. OBRC conducted an online Breastfeeding Orientation for the OK Perinatal Nurses Forum and converted a two-day class for hospital, clinic, home visiting staff, doulas, and peer counselors to a virtual format.

 

OMMB maintained operations during the pandemic with staggered staffing while continuing to screen donors, pick up raw milk, pasteurize and dispense. Some staff teleworked when possible. Donor recruitment and involvement actually increased!

 

OBRC revised the 15-hour online Baby-Friendly training for health care staff. Comanche County Memorial Hospital achieved Re-Designation and three hospitals continued designation efforts. OBRC surveyed 37 delivering hospitals to learn interest in joining BBFOK and discover what help was needed to initiate or maintain the Ten Steps. The survey resulted in requests in 19 areas from 17 hospitals, including 8 not yet committed to the project.
 

Workgroup members reviewed, updated, and worked to condense the Preparing for a Lifetime (PFL) Breastfeeding Website pages incorporating the new OK state website format, including a revised Nursing Your Newborn Fact Sheet. Breastfeeding Friendly Worksites rose to 259 recognized semi-annually through meetings and websites. One hundred and twenty of those were health care facilities and 248 were Gold Star Worksites. WIC’s Breastfeeding Task Force (WBTF) including MCH, OBRC, COBA, Indian Tribal Organizations, and partners, promoted the World Breastfeeding Week (WBW) theme, National Breastfeeding Month (NBM), and Black Breastfeeding Week (BBW) through state and community news releases, websites, and social media and WBW materials. WIC sponsored the Online Breastfeeding Educator Course for staff providing WIC services, led by Alabama’s Glenda Dickerson, MSN, RN, IBCLC, and WIC’s Breastfeeding Peer Counselor (BFPC) Program continued in 17 counties and 29 clinic sites, with 33 WIC BFPCs.

 

COBA leadership worked closely with the U.S. Breastfeeding Committee, Centers for Disease Control, MCH and WIC services to monitor and share COVID-19 recommendations and changes in accessing lactation support. Several policy positions and statements on current affairs and existing laws and policies hindering support efforts were developed and posted. Members supported the passage of two senate bills: one requiring state agencies to provide paid break time to use a designated lactation room; the other requiring state owned public buildings to provide a sanitary place (not a bathroom) with chair, working surface, and electric outlet, shielded from view and free from intrusion, to express milk or breastfeed. COBA’s online annual meeting featured a short business update and education topic.

 

MCH support continued for the OK Breastfeeding Hotline (OBH), providing information and referrals for 1,957 mothers and health care providers, and for the Hospital Breastfeeding Education (HBEP), BBFOK, and OMMB projects. The OBH launched a secure texting portal allowing users to text hotline IBCLCs, increasing contacts to 98%. Calls and texts were received from families delivering at 39 different hospitals, representing over three-fourths of OK’s birthing hospitals.

 

OMMB celebrated its seventh anniversary, serving all seven level III neonatal intensive care units (NICUs). Expanding to twenty-one depots with five in county health departments, OMMB served rural level II NICUs and special care nurseries and supported seven out-of-state hospitals without milk banks and four other milk banks with shortages. The Silas Murphy Memorial Tree was launched with over 80 plaques representing the baby of a bereaved mother who donated milk in her baby’s memory.
 

MCH promoted breastfeeding duration through OPQIC and PFL meetings, and National Nutrition Month activities. Work groups representing a variety of partners received updates and met virtually to promote activities and worksite recognition. Thirteen Area Coordinators in five statewide regions were available to assist employers to create policies, establish mothers’ rooms, and receive recognition. MCH coordinated with WIC and OBRC to update and reformat the Breastfeeding Support Fact Sheet, sharing OK’s rates and Maternity Practices in Infant Nutrition and Care (mPINC) Surveys, key outcomes and activities with legislators, health care providers, students, advocates, funders, and websites. Based on the August CDC Breastfeeding Rates Update, OK increased in three Healthy People 2020 Objectives, and equaled the national average in mPINC Rooming-In scores.

 

Objective 3: Increase the percent of Hispanic, Black, and American Indian  mothers who exclusively breastfeed their infant to 8 weeks or more from 41.0%, 44.5%, and 47.6% in 2017 to 43.1%, 46.7%, and 50.0% by 2020.

 

Data:

According to Pregnancy Risk Assessment data for 2016-2018 the rates for Hispanic, Black and American Indian mothers exclusively breastfeeding for 8 weeks or more were 39.6%, 45.9%, and 46.4% respectively. Individual year data for 2018 was not available due to not meeting the response threshold for weighting. 

 

Successes:

Efforts to address disparities focused on featuring communities of color in staff recruitment, training materials, and in selection of topics and speakers. The state’s multicultural population was reflected in brochures, websites, posters, and PSA’s.

The BBFOK Summit featured Baby-Friendly videos with stories from an African American mom and nurse. NBM celebrations targeted disparities and shared resources for communities of color. Tulsa’s Black Breastfeeding Week’s Online Celebration was led by a former COBA chair representing communities of color, as were many of COBA’s leadership and WIC BFPCs. A new nonprofit, For The Village, Inc., was formed to improve maternal and infant outcomes in the Black community by raising awareness, developing Black birth workers, and providing birth services. Queens Village, a Cincinnati group fighting high infant mortality rates disproportionately affecting Black mothers, was featured in an OK Infant Mortality Alliance Webinar. COBA members and partners supported the passage of a Senate Resolution declaring April 11-17 Black Maternal Health Week.
 

Challenges:

COVID-19 presented many challenges. Staff teleworked, conducted online meetings, and developed virtual webinars and trainings. Hospital priorities were redirected to manage the changes required to train staff, obtain supplies, and care for COVID-19 patients, so many were unable to join or participate in the BBFOK project. Multiple OSDH statewide staff operated the COVID-19 Hotline, answering questions and referring callers to available resources and services. Competing priorities and staff reductions made recruiting and retaining active work group members difficult. The state coalition worked to recruit and train members to develop leadership, communication, and financial skills to maintain and promote ongoing and new projects. OSDH’s move to a different location in the midst of a pandemic created additional challenges.

 

NPM 5: A) Percent of infants placed to sleep on their backs; B) Percent of infants placed to sleep on a separate approved sleep surface; C) Percent of infants placed to sleep without soft objects or loose bedding.

 

Objective 1. Increase the number of hospitals participating in the Safe Sleep Sack Program from 28 in 2020 to 30 in 2022.

 

Objective 2. Increase the number of trainings given to providers and professional organizations on infant safe sleep from 4 in 2020 to 5 in 2022.

 

Objective 3. Increase the number of community outreach activities by Safe Sleep Work Group members from 10 in 2015 to 15 in 2022.

 

Objective 4. Increase the number of hits for the Preparing for a Lifetime website and MCH Facebook page from 236 in 2020 to 500 hits by 2022.

 

Objective 5. Increase the percent of American Indian and African American births in hospitals participating in the Safe Sleep Sack Program, from 61.1% in 2019 to 65% in 2022.

 

Objective 6. Reduce infant mortality rate due to unsafe sleep practices for American Indian infants from 2.7 in 2018 to 2.5 by 2022 and from 3.9 in 2018 to 3.5 for African American infants by 2022.

 

Data:

Between October 1, 2019 and September 30, 2020, approximately 34,920 sleep sacks were provided to families upon discharge from the 28 participating Oklahoma birthing hospitals. Among those participating hospitals, 87.6% of 2019 births were to African American women and 61.1% to American Indian women, a slight decrease from 90.1% for African American women and 63.3% for American Indian women in 2018.

 

The percent of infants who were placed to sleep on their backs was 77.9% in 2018. This was an increase from 76.1% in 2016-2017. However, 64.6% of African American mothers reported placing their infants to sleep on their backs, compared to 80.2% of white mothers and 80.1% of American Indian mothers in 2016-2018.

 

Successes:

The Infant Safe Sleep Work Group continued to work on the work plan goals and objectives outlined in the group’s work plan under the MCH supported statewide initiative Preparing for a Lifetime, It’s Everyone’s Responsibility. This umbrella coalition, designed to reduce infant mortality and promote the health of the MCH population, was comprised of 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), local urban and rural hospitals (such as the Children’s Hospital at OU Medical Center and the Chickasaw Nation Medical Center) as well as additional community and state agencies.

 

The Oklahoma State Department of Health (OSDH) portable crib and sleep sack distribution projects were both able to complete some expansion efforts despite the difficulties of having hospital, public health, and affiliated staff focused on COVID-19 treatment, education, and mitigation. In its fifth year in FFY 2019, the portable crib project added Hillcrest Medical Center (the first hospital expansion into the Tulsa metro area) and Chickasaw Nation Medical Center, the largest hospital for patients primarily from the local American Indian community. These new partners were added to the program’s original distribution partners; home visitation programs, the Oklahoma City Indian Clinic, the OU Children’s Hospital, Mercy Hospital Oklahoma City, and Mercy Hospital Ardmore. The portable cribs continued to be distributed with culturally specific materials to qualified families on safe sleep education, along with sleep sacks. Two hundred and sixty-four portable cribs were distributed to families in need as of September 30, 2020.

 

The Chickasaw Nation Medical Center was also added to the list of birthing hospitals participating in the hospital sleep sack distribution program. The OPQI was a key partner in enrolling this hospital in the program. Hospital staff was trained in infant safe sleep, implemented written safe sleep hospital policies, signed the Infant Safe Sleep Hospital Participation Agreement, and, began distribution.

 

Despite COVID-19 hampering many other components of the projects and initiatives to bolster infant safe sleep and education across the state, the Maternal and Child Health outreach workers at the Oklahoma City-County Health Department (OCCHD) and Tulsa Health Department (THD) programs, and the Infant Safe Sleep Work Group co-lead continued to provide safe sleep education. Central Oklahoma FIMR provided train-the-trainer Infant Safe Sleep virtual sessions that resulted in approximately 431 total participants from across the state. The Tulsa Health Department (THD) FIMR group trained 57 caregivers directly in infant safe sleep, and also partnered with the Tulsa Police Department in promoting infant safe sleep in the homes where they had interactions. Finally, the Infant Safe Sleep Work Group co-lead provided education to a home for teen mothers in rural Oklahoma, home visitors in one of the rural health department clinics, and the Choctaw Nation home visiting staff.

 

Due, at least in part, to an increase in promotional campaigns and social media postings, the Preparing for a Lifetime Facebook page saw a rise in “hits” to 2,975 individuals in this period.

 

Challenges:

As with many other programs in this timeframe, COVID-19 was a significant hurdle due to time and resources pulled away from all public health projects to bolster COVID-19 education, mitigation, and treatment. The hospital partners key to these efforts were most often overwhelmed with pandemic-related tasks and as such almost any project that was not directly related to COVID-19 was placed on pause in many organizations.

 

Unfortunately, while community baby showers were a great opportunity for bringing education and resources to Oklahoma women and their partners in prior years, those that occurred annually were cancelled due to COVID-19 concerns. Preparing for Lifetime Infant Safe Sleep Work Group partners, the Oklahoma City-County Health Department (OCCHD) and Tulsa Health Department (THD) were unable to hold many community events, and did not host a community baby shower unlike previous years.

 

Unrelated to COVID-19 but still a persistent obstacle to equity is the continued racial/ethnic disparity for both safe sleep and infant mortality in the state. African Americans continued to place their babies on their back to sleep at a significantly lower rate than their white counterparts. The disparity of African American parents who shared a sleep space with their infants was also disproportionately higher. However, the back-to-sleep placement gap between the American Indian community and the white community shrank to almost no difference. When looking at co-sleeping data, although the disparity continued to persist between American Indian and white parents, it was much smaller than in the prior years measured. The infant mortality rate disparity did not improve significantly, with the White Infant Mortality Rate at 1.3, Black at 3.0, and American Indian at 2.6.

 

Despite interest from three birthing hospitals and dialogue about entering into the sleep sack distribution program, only one of those completed the requirements for participation due to COVID-19.

 

Another significant shift was the reduction in distribution of crib kits among almost all partners. When examining this shift from home visitors, this was likely due to the COVID-19 protocol ceasing all in-home visits. The reduction in hospital distribution may have also been another unfortunate circumstance of the staff being focused on COVID-19 treatment response with less time allowed for other discharge activities.

 

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, 11.1% in 2017, 11.4% for 2018, and 11.5% for 2019 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 15.8% compared to white women at 10.9%, American Indian/Alaska Natives women at 11.3%, Hispanic women at 11.0% and Asian at 10.3% and Other/Pacific Islander at 10.7%.

 

Successes:

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 prior to March 2020. Activities and opportunities to share information were very limited for the remainder of the year due to restrictions on activities and priorities for staff and partners to assist with emergency response activities.

 

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

 

Through the collaborative Focus Forward Oklahoma Initiative, the Oklahoma Health Care Authority (OHCA) led efforts to recruit and train health care providers across the state on contraceptive counseling and LARC procedures. The Focus Forward Oklahoma (FFO) Program maintained three primary strategies for addressing barriers to access of the most effective methods of contraception. These included: policy change, education, and communication. Since its inception, the program has removed restrictions on LARC (Long Acting Reversible Contraceptive) devices for SoonerCare members from the Oklahoma State Plan for Medicaid, and more recently focused policy efforts on explorations of access at health departments and Federally Qualified Health Centers (FQHCs). In particular, in partnership with OSDH, the program was able to get a Health Service Initiative through the Children’s Health Insurance Program approved to increase the number of LARC devices available to uninsured women under 19. This past year policy work has focused on creating a LARC carve out for FQHCs so that they can be reimbursed for LARC outside of the prospective payment system. Education efforts have focused on provider workforce development to increase the number of providers who provide LARC to patients. Since 2017, 29 training sessions focused on best practices in patient centered counseling and hands-on LARC procedures skills have been hosted at no cost to the trainees.

 

A total of 334 providers from across the state have been trained in the curriculum. Sixty-eight percent of providers were from the two major metropolitan areas of Oklahoma (Oklahoma City/Tulsa) and 32% were from rural areas in Oklahoma. Five provider types have attended the training sessions: 1) Physician MD, 41%; 2) Physician DO, 16%; 3) Physician Assistant, 10%; 4) Advanced Practice Registered Nurse/Certified Nurse Practitioner, 31%; 5) Certified Nurse Midwife, 1%. Four specialties were represented at the training sessions: 1) Family Practice/Primary Care, 72%; 2) Obstetrics/Gynecology, 15%; 3) Pediatrics, 8%; 4) Other (e.g. Internal Medicine, Emergency Medicine), 4%. In 2019, clinical and administrative staff training sessions were added to the program to better support provision of the full range of contraceptive options. The program has a website that houses information related to the program and resources for patients, providers, and community partners. FFO staff also continued to conduct outreach to the provider and patient community. Two MCH staff became trainers for Merck this year to assist with Nexplanon training for new OSDH staff and as part of the Focus Forward program. Birth certificate data appeared to indicate a decrease in the number of births in 2017, 2018 and 2019. Increased access to LARCs could be contributing to these changes and possibly impact the premature birth rate for unintended pregnancies in mothers with risk factors for preterm births.

 

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 in 2014. From Quarter 1, 2019 – Quarter 4, 2019, Oklahoma hospitals maintained an average PC-01 rate of 2% that equaled the national average however, the percentage of deliveries at 36-38 weeks gestation deliveries started increasing in 2019. In 2020 this increase was sustained with a rate of 35.9% of deliveries occurring between 36 and 38 weeks during the 4th quarter. Some of the increase may be result of changes in recommendations and the addition of some “indicated” conditions for early deliveries. OPQI staff also propose that rising rates of preterm births may be due to lack of enforcement of hard stop policies for scheduling inductions and cesarean sections before 39 weeks without a medical indication, documentation not reflecting appropriate medical indications, and improper coding of medical indications. The Oklahoma Perinatal Quality Improvement Collaborative (OPQIC) addressed perinatal issues identified by providers and continued to serve as the link between providers and policy-makers. 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. Reducing preterm deliveries remains a priority for this group.

 

Oklahoma continued to experience an alarming increase in the number of congenital syphilis cases. Mothers can transmit the infection to their baby before birth or through the birthing process causing miscarriage, stillbirth, death shortly after birth, prematurity and birth defects. Early testing and treatment remained the most effective method for getting ahead of the epidemic, to help ensure optimal birth outcomes. MCH staff joined the Congenital Syphilis Task Force in 2019, which advocated for testing pregnant women in the first and third trimesters. Task Force members also worked to educate Oklahomans on the risk of syphilis in pregnancy and the importance of getting treatment if caught early in pregnancy to prevent congenital transmission. While OSDH Sexual Health and Harm Reduction staff continued to track cases and educate providers, task force activities were temporarily suspended due to COVID emergency response activities.

 

Financial support of the FIMR projects at the THD and the 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. Some visits were accomplished virtually this year but most in-home visits were suspended in March due to COVID restrictions.

 

OSDH was awarded the State Maternal Health Innovation Program Grant (SMHIP) in 2019 to augment Title V activities in relation to maternal health and prenatal care. These funds are to be used to improve access to prenatal care for high risk minority populations including tribal health members and Black women across the state. With improved access to prenatal care, health care providers may be able to identify more women at risk for preterm births and ensure appropriate care is provided to help prevent additional premature births. See objective #2 for information on expanded services.

 

MCH maintained a close collaborative relationship with contractors and community partners, 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 included the rising preterm birth rate at 11.5% and the fall to an “F” on the March of Dimes grade card in 2021 despite all the work of OSDH and community partners. This is the highest preterm birth rate for Oklahoma in the last 10 years. Although collaborative partners continually review the data, no obvious causes for the increase were identified making it difficult to determine how to address the increase.

 

Additional issues included identifying causes of spontaneous preterm birth, especially in the Black population; and identifying and addressing the impact of social and racial inequities on prematurity. Disparities continued to exist in Oklahoma with the preterm birth rate among Black women 36% higher than the rate among all other women. However, the disparities are slightly better than 2019 when the Black rate was 38% higher than other women. Social determinants of health, such as income, health insurance status and prenatal care access, provided a context that could be linked to inequities in maternal and infant health outcomes.

 

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% then dipped in 2016 and 2017. The 2018 data indicate prenatal care in the first trimester was up again to 70.4%.

 

According to Oklahoma hospital discharge data, 7.0 infants per 1,000 hospital births were diagnosed with neonatal abstinence syndrome in 2018, compared with 5.0 in 2014 and 6.2 in 2016.

 

Successes:

According to the Oklahoma Health Care Authority State Fiscal Year 2020 Annual Report, 27,828 deliveries or 57.4% of all births in Oklahoma were paid for by the Medicaid programs SoonerCare or Soon-To-Be-Sooners (STBS). The Medicaid program STBS continued to provide health care benefits through the State Children's Health Insurance Program for the unborn children of pregnant females who would not otherwise qualify for SoonerCare benefits due to their citizenship status and those women with incomes between 133% of Federal Poverty Level (FPL) and 185% FPL. MCH continued to have a strong partnership with staff at the Oklahoma Health Care Authority (OHCA), the state agency that administers the Medicaid program.

 

County health department (CHD) staff continued to assist individuals and families 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.

 

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. Comprehensive Program Review visits were suspended in March due to COVID restrictions.

 

County health departments and contract providers served as safety net providers for maternity clinical services. Clinics served as the point of entry for 15,4008 females for pregnancy testing and linkage with appropriate services depending on pregnancy test results. This reflects a 22.0% decrease from the previous year, most likely due to COVID restrictions on in-person clinic visits. With the continuation of STBS as a Medicaid option for health care coverage, many pregnant women were eligible for coverage for prenatal care and delivery. However, STBS continued to be a limited benefit package. Through OPQIC meetings and partnerships it was apparent that access to care was still an issue for many women due to distance and provider availability, especially in rural areas of the state.

 

MCH continued to promote the Office of Population Affairs and the CDC’s guidelines for “Providing Quality Family Planning 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. 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/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 is included in pregnancy test counseling to help educate women with a prior preterm delivery on the importance of early prenatal care.

 

Due to the high rates of opioid use and increasing rates of newborns diagnosed and treated for neonatal abstinence syndrome, the OMNO (Oklahoma Mothers and Newborns Affected by Opioids) Work Group was established last year. Opioid prescribing guidelines for pregnant and postpartum women were developed and distributed to family practice, obstetric, and pediatric health care providers. The guidelines are available online at:  https://opqic.org/omno/maternal/. A toolkit was developed for hospitals choosing to implement the Obstetric Care for Women with Opioid Use Disorder Patient Safety bundle as part of the Alliance for Innovation on Maternal Health (AIM) Initiative. The toolkit included the prescribing guidelines, examples of universal screening tools, information on Screening, Brief Intervention and Referral to Treatment (SBIRT), information on Medication Assisted Treatment (MAT), behavioral health resources and evidence-based resources. The toolkit and the safety bundle were launched at the joint Oklahoma Perinatal Quality Improvement Collaborative/Preparing for a Lifetime Summit held September 20, 2019. There were 15 hospitals participating in the pilot group. Activities were suspended for a few months due to competing priorities for hospital staff dealing with COVID, but plans are to resume in the spring.

 

The OSDH was awarded the new SMHIP grant to address maternal morbidity and mortality in innovative ways for the next five years in 2019. This grant started October 1, 2019 with projects to address the lack of access to quality prenatal care for minority, tribal and rural women, substance use/abuse in pregnant and postpartum women, maternal morbidity, and telehealth linkages to high risk obstetrical care. Due to COVID responses and changes in staff at OSDH, contracts were delayed. However, several contracts were established including Project ECHO, Cherokee Nation, STAR clinic and CHESS Health. Contracts were put in place to establish a High Risk OB ECHO (Extension for Community Healthcare Outcomes) which provides didactic information for local OB providers on high risk conditions and case review with input from the hub team on standards of care and recommendations for quality care and referral. OSDH also contracted with Cherokee Nation to expand Maternal Fetal Medicine access within the Cherokee Nation health system. Another contract was initiated with the Oklahoma University Health Science Center Maternal Fetal Medicine STAR clinic to expand services for pregnant women with substance use disorders. A contract was also initiated 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.

 

The Maternal Health Task Force was established in partnership with the Oklahoma Perinatal Quality Improvement Collaborative through the Maternal Health Innovation Grant. A strategic map was developed with the goal of improving maternal health through comprehensive health care, both preventative and reactive, for women of childbearing age –including preconception, pregnancy, childbirth, postnatal and inter-conception care. Four priorities were identified with access to appropriate care and maternal health programs identified as priority A.

 

Challenges:

The biggest challenge this year was the impact of COVID-19 on access to in-person health care visits, restriction of family members from health care visits with pregnant women, changing the focus to telehealth visits, and access to telehealth visits in rural areas of the state without quality wireless connections.

 

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 offered a limited benefit package which only included prenatal care services that benefited the infant. Insurance coverage for this population ended at hospital discharge. Three 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.

 

Another major barrier to access was the continued lack of obstetric providers in the state and, consequently, transportation issues, which prevented women from accessing available care. Only 46 hospitals continued to provide delivery services in 28 of the state’s 77 counties.

 

Legislation was once again introduced in 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. This year, the Oklahoma State Medical Association agreed to allow practicing physicians to sign for prescriptive authority for more than two APRNs, however, the physicians have to apply, get scheduled on the agenda for an Oklahoma State Medical Association (OSMA) executive committee meeting, and attend the meeting either virtually or in-person to receive approval to sign for additional APRNs.

 

Oklahoma continued to be a state without Medicaid expansion during this time period, which impacted 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.

 

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 2019 (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.

 

In 2019, all 647 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 53 families received counseling with a board-certified genetic counselor. All newborns identified with an out-of-range CF screen were referred for genetic counseling (71 of the 74 received counseling). All cases of confirmed diagnosis for other newborn screening disorders were referred for genetic counseling and 18 received genetic counseling.

 

Successes:

Title V funding continued to support the newborn screening activities statewide. The NSP, housed within the Screening and Special Services Division of the OSDH, continued activities to educate providers and hospitals about the need for newborn screening and procedural issues regarding collecting and submitting the specimens to the Public Health Laboratory for testing. 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.

 

The NSP started the work of expanding to the four additional core conditions (Mucopolysaccharidosis Type 1 (MPS 1), Pompe, Spinal Muscular Atrophy (SMA), and X-Linked Adrenoleukodystrophy (X-ALD) legislatively approved in 2020. However, progress was halted due to resources being diverted to support COVID-19 relief efforts.

 

Long-term follow-up activities continued to include family education, and other public and stakeholder education, such as schools and transition committees. LTFU was expanded to include a second genetics clinic in OKC. The NSP and Public Health Laboratory (PHL) continued partnering with the Oklahoma Hospital Association and the Office of Perinatal Quality Improvement on the 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 took 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 monthly transit time reports to birthing hospitals and continued monitoring of provided courier services, as well as, work on reducing the number of unsatisfactory specimens submitted to the 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, Oklahoma Partnership for School Readiness, Oklahoma Parents as Teachers (OPAT), the Maternal, Infant, Early Childhood Home Visiting (MIECHV) program, the Child Abuse Training and Coordination (CATC) Program, and the Home Visitation Leadership Advisory Council (HVLAC).

 

Challenges:

Challenges related to improving newborn screening timeliness included staff being diverted to the COVID-19 response as well as difficulty with hospital engagement due to COVID-19.

 

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. MCH will evaluate and revise the Preparing for a Lifetime, It’s Everyone’s Responsibility statewide infant mortality reduction initiative, as it approaches its 15th year.

 

Data:

Partner feedback was obtained from work group participants on potential ways to increase participation and visibility of the initiative. Ideas included more in-depth discussion on timely topics from partners, redesign of the initiative’s marketing, and social media outreach, expansion of non-traditional stakeholders to invite to meetings, and movement towards a virtual platform to engage stakeholders across the state.

 

Successes:

At the suggestion of the stakeholder workgroups, it was decided to redesign the marketing and educational components of the initiative. The redesign included a new contract with Cox Media in developing and streaming updated campaigns through cable television, social media platforms, and radio spots; including satellite radio. Stakeholders began providing input on the new website design to ensure that information could be presented in an easy to acquire manner and understandable by various audiences across the state. During this time of COVID-19, stakeholders were able to continue the work of the initiative by participating in virtual meetings and inviting non-traditional partners to the table.

 

Challenges:

The primary challenge remained assuring that the partners and stakeholders needed at meetings were those in attendance. Although access to the meetings was improved due to the virtual format, COVID-19 created challenges for more participation in the stakeholders and community members due to reassignment of duties to respond to the pandemic.