Section III.A.1. Program Overview

Description of North Dakota’s maternal and child health (MCH) needs and identified Title V priorities for 2016 – 2020: As a requirement of the MCH Block Grant, states are required to develop a comprehensive, statewide needs assessment of the MCH population every five years. This needs assessment requires ongoing analysis of sources of information about MCH status, risk factors, access, capacity, and outcomes. Needs assessment of the MCH population in an ongoing collaborative process, one that is critical to program planning and development and enables the state to target services and monitor the effectiveness on interventions that support improvements in the health, safety, and well-being of the MCH population.

Through the 2016-2020 five-year needs assessment process, state Title V/MCH staff, partners and stakeholders identified the following 11 priorities across six population domains that aligned with national priority areas:

In addition to the initial needs assessment process, public/stakeholder input is gathered on a regular basis throughout the year. MCH staff provide updates on the MCH grant and grant application activities to various groups (e.g., local public health, Special Health Services Advisory Councils, ND State Council on Developmental Disabilities, Family Voices of ND). These groups have a broad range of representatives from throughout the state who provide input in directing public health efforts.

Strong partnerships with family-led organizations, county social services, local public health, tribes, universities, schools, non-profit entities, health care facilities and other state agencies provide leadership, support and advocacy in supporting and assuring comprehensive, coordinated and family-centered MCH services, including services for children with special health care needs (CSHCN). 

Five-year action plans containing evidence-based, evidence-informed and/or promising practice strategies were developed for all 11 priorities. Below is a final summary of the 2016 – 2020 priorities, including data updates, health disparity highlights and major accomplishment(s):

Women’s/Maternal Health:

• Reduce tobacco use in pregnant women

Rationale for selection in 2015: In ND, 18% of women reported smoking at any point during their pregnancy, compared to 11% nationally (2012 National Vital Statistics Reports (NVSR)). Smoking during pregnancy can cause a baby to be born too early, have low birth weight, and increases the risk of Sudden Infant Death Syndrome (SIDS).

Data update 2020 (showing progress): In ND, 10.2% of women reported smoking at any point during their pregnancy, compared to 7.2% nationally (2018 NDDoH Division of Vital Records (NDDoH DVR)).

Health Disparity: In 2019, approximately 29% of American Indian (AI) women reported smoking in their first trimester during pregnancy, compared to 11.5% of White pregnant women (NDDoH DVR).

Major accomplishment:

• Collaboration with the Tobacco Prevention and Control Program on promotion of NDQuits and Baby & Me Tobacco Free (BMTF) Programs. Birthweight data collected since July 2018 demonstrated that the average birthweight of a baby born to a BMTF program participant was, on average, 8 ounces heavier than those who were in the “pregnant smokers” category (7 pounds 9 ounces compared to 7 pounds 1 ounce).

Perinatal/Infant Health:

• Increase the rate of breastfeeding at six months

Rationale for selection in 2015: In ND, 29.1% of women reported having exclusively breastfed their infants at 6 months, compared to 25.6% nationally (2017 Centers for Disease Control and Prevention (CDC) National Immunization Survey (NIS)). Breastfeeding is associated with a reduced risk of SIDS, reduces a child's risk of becoming overweight, and has been linked to decreased risk of breast and ovarian cancer in women.

Data update 2020 (showing progress): In ND, 58.2% of women report having breastfed their infants at six months, similar to the national average of 57.6% (2018 CDC Breastfeeding Report Card). 

Health Disparity: In 2017, approximately 69.9% of ND AI mothers-initiated breastfeeding at birth, compared to 87.2% of White infants (NDDoH PRAMS).

Major accomplishments:

• Two statewide programs that support breastfeeding mothers and infants: ND Breastfeeding Friendly Hospitals and Infant Friendly Workplace. Four of the 12 birthing hospitals are designated as Breastfeeding Friendly and 155 businesses are designated as Infant Friendly.
• ND was selected to participate in the Children’s Healthy Weight Collaborative Improvement and Innovation Network (CoIIN) that resulted in collaboration in tribal communities and urban AI populations for breastfeeding support.  

• Reduce disparities in infant mortality

Rationale for selection in 2015: In ND, the AI 3-year infant death rate (11.6 per 1,000) was about 3 times greater than that of the White infant death rate (4.9 per 1,000) (2015 NDDoH DVR). Infants born to AI mothers are at much higher risk for poor birth outcomes, including being born too early, being born at low birth weight, and to die in the first year of life.

Data update 2020 (showing progress): In ND, the AI 3-year infant death rate (11.6 per 1,000) is about 2 times greater than that of the White infant death rate (4.9 per 1,000) (2015-2017 NVSR).

Health Disparity: The AI 3-year (2015-2017) sleep-related Sudden Unexpected Infant Death (SUID) rate (506.9 per 100,000 live births) is about 6.5 times greater than that of the White sleep-related (SUID) rate (78.3 per 100,000 live births). (2015-2017 NVSR)

Major accomplishments:

• Development of a safe sleep messaging campaign that incorporates other risk reduction education including smoking cessation, secondhand smoke exposure and the benefits of breastfeeding.
• All 12 birthing hospitals signed the ND Safe-to-Sleep Pledge; one hospital has reached gold level certification through the National Cribs for Kids program.  
• Implementation of Count the Kicks, a stillbirth prevention public health campaign.

Child Health:

• Reduce overweight and obesity in children

Rationale for selection in 2015: In ND, 36% of children and teenagers ages 10 through 17 were considered overweight to obese, compared to 31% nationally (2011/2012 National Survey of Children’s Health (NSCH)). Children that are overweight have an increased risk for heart disease, diabetes, asthma, and low-self-esteem.

Data update 2020 (showing progress): In ND, 30% of children and teenagers ages 10 through 17 are considered overweight to obese, compared to 31% nationally (2016-2017 NSCH). 

Health Disparity: In ND, 18.6% of females ages 10 through 17 were overweight, compared 16.4% of males (2016-2017 NSCH).

Major accomplishments:

• Development of a “Train the Trainer” curriculum – Shaping the First Five Years with Active Play and Healthy Eating – related to nutrition and physical activity best practices for early care and education providers. 
• Development of a wellness policy that identifies what schools should be working toward for improvement (e.g., policy, nutrition standards, physical activity, school sponsored activities, hydration standards).

• Increase preventive dental services to children

Rationale for selection in 2015: In ND, 20.7% of third graders had untreated decay, compared to 25% nationally (2010 ND Third Grade Basic Screening Survey (BSS)).

Data update 2020 (decline in progress): In ND, 23% of third graders had untreated decay, compared to 22% nationally (2018 BSS).

Health Disparity: Dental decay among ND third graders was more prevalent among AI children (88%), compared to White children (67%) (2018 BSS).

Major accomplishments:

• Medicaid reimbursement for public health hygienists that provide services for Seal!ND, a school-based fluoride varnish and sealant program.
• A public health hygienist employed in a medical facility that provides oral health screenings, fluoride varnish, education, referrals and care coordination to low-income and uninsured individuals.
• A strong community water fluoridation program; 97% of ND’s community water systems have optimally-fluoridated water.

Adolescent Health:

• Reduce fatal motor vehicle crash deaths to adolescents

Rationale for selection in 2015: In ND during 2009-2011, unintentional injuries among youth ages 15 through 24 due to motor vehicle crashes ranged from 16 to 27 per 100,000 (NDDoH DVR). Motor vehicle crashes are the number one killer of teenagers; young drivers are twice as likely as adult drivers to be in a fatal crash.

Data update 2020 (decline in progress): In 2017, the rate of fatal unintentional injuries among youth ages 15 through 24 due to motor vehicle crashes in ND was 41.5 per 100,000 (NDDoH DVR).

Health Disparity: In 2017, ND males (48.9) had a higher mortality rate compared to ND females (22.63) (NDDoH DVR). Additionally, while only 32% of motor vehicle crashes in ND occurred on rural roads between 2013 and 2017, these rural crashes accounted for 87% of all fatal crashes in the state and 70% of all severe crash-related injuries (2018 ND Department of Transportation).

Major accomplishments:

• Expansion of Impact Teen Drivers: an evidence-based program that uses engaging awareness and educational materials for teens, parents, teachers and health professionals.
• Vison Zero – a comprehensive, multi-agency effort to work toward zero motor vehicle fatalities and serious injuries on ND roads.  

• Decrease depressive symptoms in adolescents

Rationale for selection in 2015: In ND, 25% of adolescents reported having depressive symptoms (feeling sad and/or hopeless) and/or being bullied in the past 12 months (2013 ND Youth Risk Behavioral Survey (YRBS)). Bullying is a major public health problem that is linked to depression, antisocial behavior, suicidal thoughts, poor school performance, etc.

Data update 2020 (decline in progress): In ND, 30.5% of adolescent’s report having depressive symptoms and/or being bullied in the past 12 months (2019 ND YRBS).

Health Disparity:  In 2017, approximately 24% of ND high school girls seriously contemplated suicide, compared to 17% of high school boys (ND YRBS).

Major accomplishments:

• Sources of Strength – an evidence-based suicide, substance use, and bullying prevention program implemented in 50 schools.
• Transition of the Suicide Prevention Program from the NDDoH to the Department of Human Services, Behavioral Health Division, to enhance coordination across the behavioral health continuum of care. 

Children with Special Health Care Needs (CSHCN):

• Increase the utilization of medical home

Rationale for selection in 2015: In ND, 48% of families of CSHCN ages 0 to 18 reported having received coordinated, ongoing, comprehensive care within a medical home. Children with a medical home are more likely to receive preventive care, are less likely to be hospitalized, and are more likely to be diagnosed early for chronic or disabling conditions (2009-2010 NSCH).

Data update 2020 (showing progress): In ND, 43.2% of families of CSHCN, ages 0 to 18, report having received coordinated, ongoing, comprehensive care within a medical home (2016-2017 NSCH).

Health Disparity: In ND, only 43.2% of CSHCN received coordinated, ongoing, comprehensive care within a medical home, compared to non-CSHCN (49.8%) (2016-2017 NSCH).

Major accomplishment:

• Formation of a Well-Child Check Collaborative focused on increasing ND well-child check rates, advocating for quality care within a medical home, and execution of age-appropriate developmental screenings.

• Increase the number of children with special health care needs receiving transition support

Rationale for selection in 2015: In ND, 47% of parents of CSHCN reported having adequate resources for their child's transition into adulthood (2009-2010 NSCH). Children who do not receive transition services are more likely to have unmet health needs as adults.

Data update 2020 (decline in progress): In ND, 21.4% of CSHCN received services necessary to transition to adult health care (2016-2017 NSCH).

Health Disparity: In ND, adolescent males (17.8%) are less likely to receive services necessary to transition to adult health care compared to females (24.7%) (2016-2017 NSCH).

Major accomplishments:

• Creation of a Health Snapshot Pocket Guide to assist youth with gathering their medical information and begin the transition to adult health care, and a health care transition toolkit for use by pediatric health providers.  

Cross-cutting/Systems Building:

• Increase adequate insurance coverage to the MCH population

Rationale for selection in 2015: In ND, 23% of non-CSHCN did not have adequate health insurance, compared to 28% of CSHCN (2011/2012 NSCH).

Inadequate insurance can lead to delayed or foregone care. 

Data update 2020 (decline in progress): In ND, 35.4% of non-CSHCN did not have adequate health insurance or had a gap in health insurance coverage in the last year, compared to 44.6% of CSHCN (2016-2017 NSCH).

Health Disparity: ND parents with social-economic disparities are less likely to have adequate insurance to meet their medical and dental needs (2016-2017 NSCH).

Major accomplishments:

• Title V/MCH staff disseminate information on insurance or other coverage options and provide navigation support through referral training and education for families, local staff, and partners.
• During federal fiscal year 2018, Special Health Services provided gap-filling diagnostic and treatment services to 221 CSHCN and their families.

• Implement North Dakota state mandates delegated to the North Dakota Department of Health Title V / Maternal and Child Health Program

Rationale for selection: Priorities are often influenced by state mandates, which are generally reflective of expressed need within the state.

Major accomplishment:

• During the 2019 Legislative Session, ND’s Safe Haven’s law was updated and directed the NDDoH to develop a public awareness campaign. Two public service announcements explaining what safe haven is were produced and have been aired on the Health Alert Network, which plays at over 80 health care sites including local public health and Federally Qualified Health Centers.      

North Dakota’s priorities for 2021 – 2025 have been developed through a Work-As-One Needs Assessment Integration Initiative:

• Well-woman care, with an emphasis on minority and low-income women
• Breastfeeding, with a priority among American Indian women
• Physical activity and nutrition (overall obesity prevention)
• Adolescent well visit, with an emphasis on overall health, including depression screening, obesity prevention, and immunization
• Transition (medical home to medical home)
• Vision Zero – eliminate fatalities and serious injuries caused by motor vehicle crashes
• Workforce development
• Implement ND mandates for the MCH population