Section III.C. Needs Assessment Update

 

2024 Needs Assessment Approach

The 2024 needs assessment and its update will address the changes in the health, health care access and utilization, and mortality trends of women/mothers, perinatal/infants, children, and adolescents during the last five years in North Dakota. Disparity factors will be discussed that have been identified in the state, such as: women age, mother’s residency (urban vs. rural), mother’s race, economic status, and health insurance status, among others.   

 

A state health assessment was conducted by North Dakota State University, Center for Social Research, and includes MCH as an integral piece of the assessment; hence, some of the elements of this process were included in this assessment around mortality and severe morbidity and hospitalizations. This section also includes results from the North Dakota Pregnancy Risk Assessment Monitoring System (PRAMS), a collaborative monitoring project between the North Dakota Department of Health and Human Services and the Centers for Disease Control and Prevention (CDC), which spans the years 2017–2022. This needs assessment also includes information from the CDC's North Dakota Behavioral Risk Factor Surveillance System (BRFSS) for Women of Reproductive Age (18-44), which was designed to collect monthly data from 2017 to 2021 on health-related symptoms, hazardous behaviors, and preventative health actions. Additionally, the assessment includes the findings from the North Dakota State Health Improvement Plan (SHIP) Key Informant Survey conducted in 2023 and the North Dakota Infant Mortality study, where data was extracted from linked birth/infant death records covering the years 2018-2022.

 

With these main sources of data, as well as national survey data, we have a complete picture of the health status of the women, mothers, infants, children, and adolescents in North Dakota. Additional information about the State Health Assessment and the SHIP can be found at https://www.hhs.nd.gov/health/north-dakota-state-health-improvement-plan-ship.

 

Women’s and Maternal Health

North Dakota continues to be one of the fastest-growing states in the nation, with over a 15.9 percent population increase between 2010 (672,591) and 2022 (779,261).¹ Population growth has, in part, been due to an increase in fertility rates. According to 2022 North Dakota Department of Health and Human Services (NDDHHS) Division of Vital Records Data the fertility rate among women ages 15 to 44 in the state was 63.03 per 1,000 women, substantially higher than the United States provisional fertility rate of 56.1 births per 1,000 women aged 15-44.²,³

 

Birth rates among Native American Indian (NAI) are higher than among White (16.82 vs.11.63).4 The rate of teen live births in North Dakota (12.29 per 1,000 females less than 20 years of age in 2022) is lower than national rates (13.6 per 1,000 females 15 to 19 years of age in 2022).5 NAI teenagers in North Dakota had substantially higher pregnancy rates than White teenagers.  From 2016 to 2022, NAI teen pregnancies were almost two times that of White teenagers, 6.4 teenage births per 1,000 live births, compared to 3.4 teenage births per 1,000 live births, respectively.3

 

Of all live births in North Dakota during 2020-2022, 3.2% were to women under the age of 20, 51.2% were to women ages 20-29, 43.4% were to women ages 30-39, and 2.2% were to women ages 40 and older.3 Babies delivered to younger and older women are often at increased risk of poor birth outcomes, including prematurity, low birthweight, and infant mortality.6

 

Most women who gave birth in 2022 in North Dakota received prenatal care; 80.9% of women received first-trimester prenatal care, 12.8% percent of women received care in the second trimester and 6.2% of women received late or no prenatal care.7 In North Dakota during 2020-2022, White (85.7%) mothers had the highest rates of early prenatal care, followed by Asian/Pacific Islanders (73%), Blacks (68.5%) and American Indian/Alaska Natives (47.3%).8  

 

In looking at the 2017 through 2022 Pregnancy Risk Assessment Monitoring System (PRAMS) data, several differences were observed in the proportion of women who did not initiate prenatal care during the first trimester by race and by mother’s residence (urban/rural). In 2022, a lower percentage of NAI women initiated prenatal care in the first trimester (74.7%) compared to Whites (93.5%). In addition, a lower percentage of the recommended number of visits was observed in mothers residing in rural areas (36.4%), compared to urban areas (50.2%). Lastly, it was identified that 47.4% of White women received 12 or more prenatal care visits in 2022 versus NAI women at 19%.9

 

Next, the Kotelchuck index was calculated, using the data on the initiation of prenatal care and the number of visits.  To classify the adequacy of received services, the number of prenatal visits is compared to the expected number of visits for the period between when care began and the delivery date. The expected number of visits is based on the American College of Obstetricians and Gynecologists prenatal care standards for uncomplicated pregnancies and is adjusted for the gestational age when care began and for the gestational age at delivery. A ratio of observed to expected visits is calculated and grouped into four categories:

• Inadequate (received less than 50% of expected visits)
• Intermediate (50%-79%)
• Adequate (80%-109%)
• Adequate Plus (110% or more)

 

The results for the Kotelchuck index suggest that American Indian women, adolescent girls, those living in rural areas, and those without health insurance showed a higher percentage of inadequate prenatal care. See the graphs below for more detail.

 

 

Additionally, the map below shows the percentages of inadequacy by county. *Williams, Sioux*, Sheridan, Benson*, and Rolette* counties show the highest percentages in the inadequate category compared to the rest of the counties in the state. *Williams, Sioux, and Rolette have been identified as high-vulnerability counties (2022 overall SVI score).10 As of 2022, 50 of the 53 North Dakota counties are partially or fully designated as HPSA and/or Medically Underserved areas.  The same is observed for the state's dental health and mental health.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In North Dakota, 71.4% of counties are maternity care deserts, compared to 32.6% of counties in the U.S. overall.  Furthermore, 45.3% of babies were born to women who live in rural counties, while 26.9% of maternity care providers practice in rural counties in North Dakota. On average, women in North Dakota travel 32.4 miles to the nearest birthing hospital11,12

 

 

 

 

 

 

Next, 8% of women of reproductive age (15-44 years) were uninsured in 2021, and 22.3% were on North Dakota Medicaid at the time of birth (2022). From 2020 to 2022, there was a slight decrease in the percentage of women receiving North Dakota Medicaid (2.3%).13

 

According to vital record data, a total of 998 deaths occurred among women aged 18-44 in North Dakota from 2017 through 2022. The most frequently reported causes were categorized as accident or injury (275), others (242) cancer (106), and suicide (106). Of this total, 20 women were pregnant at the time of death, and an additional 20 were pregnant within 1 year of death.3

 

 

 

To analyze trends in mortality and severe morbidity in the MCH population, the Special Projects & Health Analytics division in Health Statistics and Performance (HSP) operates data dashboards to summarize vital records and hospital discharge data in an effort to visualize key findings of the statewide health assessment. Hospital discharge data indicates that 1,350,006 hospitalizations among women aged 18 to 44 occurred from 2016 through 2022. The most common services were obstetrics, general medicine, general surgery, psychiatry, and orthopedics with an average length of stay of 3.65 days. The average treatment cost of the top 5 inpatient services for this population was over $21,792.54 and, in total, over $25,998,980,487.44 million was spent on inpatient treatment costs of women aged 18 to 44.3

 

The next table shows ND BRFSS 2917-2021 data. Frequent mental distress (FMD) (i.e., 14 or more days of self-described poor mental health in the last month) was relatively common in this population (19%). The prevalence of smoking (17%) and obesity (28%) were also high. Approximately 14% of the population had some medical cost in the previous 12 months that they were unable to afford.

 

 

ND BRFSS data: Prevalence of chronic conditions and risk factors among North Dakota women aged 18–44 years, 2017–2021.
Category	Prevalence	95% Confidence Interval
Diabetes	3%	2%, 3%
Hypertension	7%	6%, 8%
Frequent Mental Distress (FMD)	19%	18%, 21%
Frequent Physical Distress	9%	7%, 10%
Obesity	28%	26%, 30%
No physical activity	22%	20%, 24%
Checkup >1 year ago	15%	15% 17%
Inhibitive medical cost	14%	12%, 16%
Smoking	17%	15%, 19%
Heavy Drinking	8%	7%, 9%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

According with the results of this study, the prevalence of FMD is substantially higher among women of reproductive age than older women or males.  Prevalence of FMD was lowest among Black and White women (15% and 19%, respectively), and higher among American Indian (24%) and Other Race/Ethnicity (26%). Prevalence of FMD varied strongly depending on education level. Prevalence among women with a high school education or less was 27% (95% CI = 23%, 32%) compared to a prevalence of 16% among women with more than a high school education (95% CI = 18%, 23%). 14 Approximately 28% of these women were obese.  Among these women, obesity prevalence was substantially higher among the NAI population (52%) than any other race/ethnicity.14 Approximately 85% received a healthcare checkup in the last 12 months.  The White population had the highest prevalence of not having a checkup within the last 12 months. All other races or ethnicities had similar prevalences.14 Approximately 14% of these women were unable to afford some needed medical care in the previous 12 months. Prevalence of unafforded medical costs among women of reproductive age differed by race/ethnicity. White women had the lowest prevalence of unafforded medical costs (12%) followed by American Indian (16%), Other Race/Ethnicity (19%), and Black (27%). The prevalence of unafforded medical costs among women of reproductive age was notably higher among those with a high school education or less (prevalence = 19%) than those with more than a high school education (11%).14

 

Women of reproductive age smoke at a higher rate (17%) than women aged 45 years or older (14%). Smoking prevalence among women of reproductive age was substantially higher in the NAI population (prevalence = 40%) than any other racial or ethnic group. The prevalence of smoking among women of reproductive age was substantially higher among people who had a high school education or less (prevalence = 29%) than those who had more than a high school education (12%).14 Women of reproductive age reported a higher prevalence of heavy drinking (8%) than women aged 45 years or older (5%). Heavy drinking prevalence among women of reproductive age was slightly higher in the NAI population (prevalence = 10%) than other racial and ethnic groups. The prevalence of heavy drinking among women of reproductive age was higher among people who had a high school education or less (prevalence = 10%) than those who had more than a high school education (7%). Heavy drinking was more prevalent among reproductive-aged women who had frequent mental distress than those who did not.14 The map below shows the results by county.  Most of the counties/areas with high percentages are also designated health professional shortage areas (HPSAs).  These HPSAs are federal designations that apply to areas, population groups, or facilities in which there are unmet health care needs.  Population groups include those considered to be low-income (at or below 200% of the federal poverty level), groups on Medicaid, migrant farm workers, tribal, or homeless populations, among others.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

North Dakota trends in pregnancy and birth rates, 2015 to 2022

Over the past five years, a decrease in both pregnancy and birth rates has been observed.

 

Perinatal and Infant Health

According to the results of the 2021-2022 (combined data) National Survey of Children's Health (NSCH), 93% (92.9% Nationwide) of children in the state had health insurance.  An estimated 59.9% of children in the state had continuous and adequate health insurance for child’s health needs.15

 

The rate of low birthweight is slightly better than national rates, 7% in North Dakota, compared to 8% nationally.15 Between 2011 and 2022, the rate of infants born low birthweight in North Dakota declined more than 1%.16

 

Infant Mortality

According with North Dakota vital record data, between 2018 and 2022, North Dakota recorded a total of 228 infant deaths. The Infant Mortality Rate (IMR) was higher in mothers residing in rural and semi-urban areas, reaching the highest IMRs observed 2019-2020 (8/1000 live births).  Compared to mothers of white and black races, NAI mothers had a higher IMR, with the highest rates observed 2019-2020 (12.5-14.9/1000 live births).  Black mothers follow, with an increase in mortality rates in the last two years (6/1000 live births). 9.3% of infant deaths between 2018-2022 occurred among Hispanic mothers. Infants born to adolescents were linked to most of the infant deaths across all years, with the highest proportion among AI mothers.  However, in 2022 the IMR among adolescents was reduced by more than half compared to 2019.  For the five years of analysis, the primary source of payment for pregnancies resulting in infant mortality were Blue Cross Blue Shield and North Dakota Medicaid. Over the years, there has been an increase in the percentage of infant deaths with North DakotaMedicaid as the primary source of payment (2018:26%; 2022: 40.5%). The average number of prenatal care visits remained constant over these five years from 6 to 7 visits on average, less than the recommended number of prenatal care visits (10).  NAI mothers showed the lowest average number of prenatal care visits (5).  Mothers residing in rural and semi-urban areas have a lower average number of prenatal visits (6 vs. 7) compared to urban areas.

 

The top five underlying causes of death for infants from 2018 through 2022 were perinatal diseases; congenital malformations and chromosomal abnormalities; unclassified symptoms, signs and laboratory findings; accidents and assaults; and infectious diseases collectively representing 93.8% percent of all causes of death among infants.3

 

Child Health

Among children, from 2017 through 2022, 2778 deaths occurred among North Dakotans aged 0 to 19 years old. Of these, 56.5% occurred among male children, 43.5% female children.3 Among the children’s death 83.20% were white, followed by 12.96% American Indians, 2.97% black and 0.87% Asian/other pacific Islander/ Native Hawaiian/ Guamanian/ Samoan.3

 

The underlying cause of death for this age group were most frequently categorized as other causes (58.9%) accident or injury (20.0%), suicide (9.6%) and cancer (4.0%).3

 

Hospital discharge data from 2016 to 2022 in children aged 0-18 describe over 675,888 inpatient hospitalizations, most frequently utilizing neonatal, newborns, general medicine, psychiatry, and general surgical. The average length of stay for the top 5 common services for North Dakota children during this time was 8.64 days. The average cost of treatment for the top 5 common services inpatient hospitalizations among children was $ 44,572.01 with a total inpatient expenditure of over $27 billion from 2016 through 2022.3

 

Children with Special Health Care Needs

According to data from 2021 to 2022 National Survey of Children with Special Health Care Needs (NSCH) in North Dakota, 5.6% percent of children with special health care needs (CSHCN), ages 0 through 17, received care in a well-functioning system compared to 7.4% nationally. Among the components of a well-functioning system only 24% of CSHCN received transition among adolescents, 60.2% had preventive medical and dental care, 59.9% had continuous and adequate insurance, only 52.3% had medical home and 75.3 % were involved in shared decision-making if it was needed. Among CSHCN, only 41.4% with 2 or more ACE’s, 8.3% of children ages 0 through 5, 20.3 of children ages 6 through 11, 26.6% of children ages12 through 17, 4.2% of children whose parents whose household income-poverty ratio at 100%-199%, 17.5% with household structure comprising of single parent, 12.3% males, and 5.1% received care in a well-functioning system.15

 

According to data from 2019 to 2020 NSCH, in North Dakota, 25% of adolescents with special health care needs, ages 12 through 17, received services necessary to make transitions to adult health care compared to 22.1% CSHCN nationally. Among Non-CSHCN, 23.5% in North Dakota received services necessary to make transitions to adult health care compared to 16.2% nationally. Among the components for transition for CSHCN receiving services necessary to make transitions to adult health care: 53% of CSHCN received time alone with provider, 59.8% of the providers actively worked with the child.15

 

WELLNESS: Adverse Childhood Experiences Prevention Efforts

According with the results from the ND SHIP key informant survey, the vast majority of respondents indicated that the issue of preventing adverse childhood experiences is very (39%) or extremely (45%) important in North Dakota's effort to become the healthiest state in the nation.17

 

Current Involvement

One-third of respondents reported involvement in prevention efforts around adverse childhood experiences (35%). For those respondents involved in adverse childhood experiences prevention efforts (n=52), most were affiliated with organizations serving all 53 counties in the state (39%). Nearly one-third of respondents served only one county (31%) and 29% served a combination of counties. Most respondents involved in prevention work around adverse childhood experiences were affiliated with the health sector (35%). One-fourth of respondents were with government and education (28% each), 8% were in human services, and 2% were with housing and development. One in five respondents indicated a tribal affiliation (21%).17

 

Interest in Collaboration with NDDHHS

Four in 10 respondents expressed an interest in collaborating with NDDHHS on prevention efforts around adverse childhood experiences (40%). For those respondents with an interest in collaborating (n=60), two-thirds were already involved in these prevention efforts (67%). Four in 10 respondents with an interest in collaborating were affiliated with organizations serving only one county in the state (40%). Similar percentages served a combination of counties (30%) and all 53 counties in the state (30%). Most respondents interested in collaborating with NDDHHS on prevention efforts around adverse childhood experiences were affiliated with the health sector (40%), 28% were with education, 18% were with government, 8% were in human services, and 2% each were with housing and development and the cultural sector. One in five respondents indicated a tribal affiliation (20%).17

 

Adolescent Health

According to 2022 US Census Bureau population estimates, 24.0% of the population in North Dakota is under eighteen years of age.18 Younger people are at risk of poor health and behavior choices, particularly when involved with drugs and alcohol.  North Dakota is also affected by the behavioral health crisis facing the nation.  Approximately 21.56% percent of adolescents and 10.34% percent of adults reported at least one major depressive episode in the preceding year. Of particular concern was the rate of binge alcohol use in the previous month among those over the age of 12. North Dakota ranked fourth out of 50 states, with a binge alcohol use rate of 26.72%, compared to a low of 13.69% in Utah. Binge Alcohol Use is defined as drinking five or more drinks (for males) or four or more drinks (for females) on the same occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past 30 days. Additionally, 19.68% of North Dakota residents over the age of 12 reported a substance use disorder, compared to the US average of 17%.19 The state ranks 5th nationally in suicides rates with 22 suicides per 100,000 and was the 3rd leading cause of death in 2022.3,20

 

Conclusion

Health disparities among American Indian populations, adolescent girls, those in rural areas, and the uninsured rural are evident across nearly all MCH indicators. The findings from this assessment will help to guide programs and policies to address the state’s need for maternal and child health services. 

 

References:

1. S0101: AGE AND SEX - Census Bureau Table. (n.d.). Retrieved May 30, 2024, from https://data.census.gov/table/ACSST5Y2020.S0101?g=040XX00US38

2. NVSS - National Vital Statistics System Homepage. (2024, May 1). https://www.cdc.gov/nchs/nvss/index.htm

3. Vital Records. (n.d.). Health and Human Services North Dakota. Retrieved May 30, 2024, from https://www.hhs.nd.gov/vital

4. CDC WONDER. (n.d.). Retrieved May 30, 2024, from https://wonder.cdc.gov/

5. FastStats. (2024, April 25). https://www.cdc.gov/nchs/fastats/teen-births.htm

6. Percentage of births by maternal age: North Dakota, 2020-2022 Average. (n.d.). March of Dimes | PeriStats. Retrieved May 30, 2024, from https://www.marchofdimes.org/peristats/data?top=2&lev=1&stop=2&reg=99&sreg=38&obj=1&slev=4

7. Late/no prenatal care by race/ethnicity: North Dakota, 2020-2022 Average. (n.d.). March of Dimes | PeriStats. Retrieved May 30, 2024, from https://www.marchofdimes.org/peristats/data?reg=99&top=5&stop=28&lev=1&slev=4&obj=1&sreg=38&creg

8. Early prenatal care by race: North Dakota, 2020-2022 Average. (n.d.). March of Dimes | PeriStats. Retrieved May 30, 2024, from https://www.marchofdimes.org/peristats/data?top=2&lev=1&stop=2&reg=99&sreg=38&obj=1&slev=4

9. Pregnancy Risk Assessment Monitoring System (PRAMS). (n.d.). Health and Human Services North Dakota. Retrieved May 30, 2024, from https://www.hhs.nd.gov/prams

10. CDC|ATSDR Social Vulnerability Index (CDC|ATSDR SVI). (2024, May 21).

 http:// www.atsdr.cdc.gov/placeandhealth/svi/index/html

11. Maternity Care Desert: North Dakota, 2021. (n.d.). March of Dimes | PeriStats. Retrieved May 30, 2024, from https://www.marchofdimes.org/peristats/data?top=2&lev=1&stop=2&reg=99&sreg=38&obj=1&slev=4

12. Maternity-Care-Report-NorthDakota.pdf.(n.d).Retrieved May 30,2024, from

https://www.marchofdimes.org/perostats/assessts/s3/reports/mcd/Maternity-Care-Report-NorthDakota.pdf

13. Uninsured women: North Dakota, 2011-2021. (n.d.). March of Dimes | PeriStats. Retrieved May 30, 2024, from https://www.marchofdimes.org/peristats/data?top=2&lev=1&stop=2&reg=99&sreg=38&obj=1&slev=4

14. North Dakota Behavioral Risk Factor Surveillance System. (n.d.). Health and Human Services North Dakota. Retrieved May 30, 2024, from https://www.hhs.nd.gov/data/north-dakota-behavioral-risk-factor-surveillance-system

15. NSCH Interactive Data Query (2022—Present)—Data Resource Center for Child and Adolescent Health. (n.d.). Retrieved May 30, 2024, from https://www.childhealthdata.org/browse/survey#52_36

16. Muganda, C. (2022). 2022 North Dakota County Health Rankings.

17. North Dakota State Health Improvement Plan—SHIP. (n.d.). Health and Human Services North Dakota. Retrieved May 30, 2024, from https://www.hhs.nd.gov/health/north-dakota-state-health-improvement-plan-ship

18. Bureau, U. C. (n.d.). NSCH Datasets. Census.Gov. Retrieved May 30, 2024, from https://www.census.gov/programs-surveys/nsch/data/datasets.html

19. 2021-2022 NSDUH: Model-Based Estimated Prevalence for States | CBHSQ Data. (n.d.). Retrieved May 30, 2024, from https://www.samhsa.gov/data/report/2021-2022-nsduh-state-prevalence-estimates

20. Stats of the State—Suicide Mortality. (2023, February 15). https://www.cdc.gov/nchs/pressroom/sosmap/suicide-mortality/suicide.htm