New Data Collection & Analysis Efforts

 

Neonatal Abstinence Syndrome Surveillance Data

 

The TDH Neonatal Abstinence Syndrome (NAS) Surveillance Program was established in 2013 when NAS first became a reportable condition. Despite progress in addressing the opioid epidemic and improvements in care for the pregnant woman-infant dyad, NAS remains a significant public health threat in Tennessee and the need for timely data remains. Since being added to the reportable disease list, TDH had seen annual increases in the number of cases of NAS until 2018, which marked the first decrease in the number of cases. During the 2022 surveillance period, 797 cases of NAS were reported to the TDH surveillance portal, which is a slight, yet statistically insignificant, increase from the prior year (n=758). Tennessee’s NAS rate (9.8 per 1,000 live births) remains markedly higher than the national rate (6.3 per 1,000 live births; based on 2020 data, the most recent data available). In addition, rates of NAS remain highest in the eastern part of the state.

 

Family Planning Telehealth Patient Satisfaction Survey

 

The Family Planning Telehealth Program implemented a patient satisfaction survey starting in 2021. Data are collected on an ongoing basis and were analyzed in October 2023. Between November 1, 2021, and September 30, 2023, there were 1,582 Family Planning Telehealth encounters and 343 survey responses, for a response rate of 22%. Among respondents,

• The majority (81%) reported Family Planning Telehealth was their first experience with telehealth, with most (80%) reported using audio and visual through their own phone or computer.
• The most common benefits reported among respondents were not having to wait for an in-person appointment (75%) and decreased transportation time.
• Almost all respondents (99.7%) were given clear instruction on how to obtain their method of choice; among respondents, 61% selected birth control bills.
• The vast majority of respondents (96%) were satisfied with their Family Planning Telehealth visit and 95% would recommend Family Planning Telehealth to friends and family.

 

Pregnancy Risk Assessment Monitoring System (PRAMS)

 

Tennessee PRAMS conducted new analyses on stress before or during pregnancy and the impact on both preterm birth and low birth weight outcomes and created a fact sheet, highlighting common stressors included: moving to a new address (37%), a family member sick or in the hospital (26%), arguing more than usual with a partner (24%), and problems paying the bills (21%). Demographic groups experiencing more stress included: non-Hispanic Black women, unmarried women, women who reported depression prior to pregnancy, women aged less than 20 years, and those with Medicaid insurance coverage at delivery. TN did not find that overall stress to be associated with birth outcomes; however, analyses noted non-Hispanic Black women had a higher likelihood of low birthweight and preterm birth regardless of stress experiences.

 

Tennessee PRAMS also conducted new analyses on postpartum depressive symptoms, creating a fact sheet. In Tennessee, one in six women reported postpartum depressive symptoms during 2016-2019. The strongest factors associated with postpartum depressive symptoms included: depression prior to pregnancy, intimate partner violence, smoking prior to pregnancy, and preterm birth.

 

According to the most recent PRAMS data, from 2017 to 2021:

• Nearly 90% of Tennessee women with a recent live birth reported that babies are most often laid to sleep on their backs compared to the U.S. average (80%).
• Fewer Tennessee women (21.5%) reported having a mistimed pregnancy compared to the U.S. (18.4%).
• While more Tennessee women (80.5% vs. 75.5%) reported using any postpartum contraceptives compared to the U.S. average, fewer women in Tennessee (21.6%) reported using any of the least effective postpartum contraceptive methods compared to the U.S. average (22.9%).
• Fewer Tennessee women (9.2%) reported being uninsured after pregnancy compared to U.S. women (9.4%).
• Cigarette smoking in Tennessee women before (20.3%), during (10.4%) and after (14.1%) pregnancy was more common compared to U.S. women (15.1%, 6.9%, and 9.7% respectively).
• Fewer Tennessee women (55.4%) reported receiving a flu shot before delivery compared to U.S. women (59.2%).
• More women in Tennessee (15.4%) reported experiencing postpartum depressive symptoms compared to U.S. women (13.1%).

 

National Survey of Children’s Health Oversample

Through collaboration with the Division of Health Disparities Elimination, FHW applied for an oversample of Black and Hispanic respondents for the National Survey of Children’s Health starting in 2022 for an initial period of two years. They were able to achieve more than 250 Non-Hispanic Black interviews and over 200 Hispanic interviews. The initial results of the oversample became available in in October of 2023. The data will be utilized in the quantitative data collection for the 2025 needs assessment. Current planned analyses include oral health as well as analyses on social determinants of health like healthcare access, housing and food Insecurity, social support, and neighborhood cohesion.

 

Severe Maternal Morbidity Analyses

In 2021 – 2022, FHW, in partnership with the TDH Office of Informatics and Analytics, successfully added and linked birth certificate data into the Integrated Data System (IDS), through support of the HRSA Emerging Issues in MCH grant. In 2023, two FHW epidemiologists supporting the Maternal Health Innovation grant were approved for access to the IDS to complete analysis for severe maternal morbidity using linked birth certificate and hospital discharge data. The benefits of IDS are that the data linkage is standardized and provides increased reliability and quality control. In addition, the data is geocoded which provides more opportunity for further data analysis. Currently there are plans for a larger analysis of Severe Maternal Mortality (SMM) data to create a summary report and fact sheets.

Preliminary key findings from SMM analysis from 2018 to 2022 include:

• SMM rate in Tennessee increased by 14% from 2018 to 2022 (71.4 per 10,000 deliveries in 2018 to 81.4 in 2022).
• Black non-Hispanic women had the highest SMM rate (109.5 per 10,000 deliveries) compared to White non-Hispanic women (68.3) and Hispanic women (65.7)
• Leading indicators of SMM (excluding blood transfusions) were disseminated intravascular coagulation (20.3), acute respiratory distress syndrome (12.8), acute renal failure (11.5), hysterectomy (11.4), and eclampsia (10.5).
• Leading complications (SMM groupings) were hemorrhage (32.8), other obstetric (15.0), respiratory (13.5), renal (11.5), and cardiac complications (10.0).
• SMM rates were highest among older women ages 40 years and older (159.1) than any other age group.
• Women insured by Medicaid or Medicare had higher SMM rates (90.3) compared to women with private/other insurance (66.4) and other public (82.1).
• Deliveries in small and medium metropolitan areas had the highest SMM rates (83.1) compared to large metro (78.9) and rural areas (69.4).

 

Tennessee Department of Health Roadshows

The Tennessee Department of Health (TDH) initiated the "Roadshow" to bridge the gap between local health departments across the state and the central office in Nashville, TN. What began with one employee traversing the state has evolved into multiple offices and departments from the central office traveling to discuss a range of services and opportunities. The Roadshow serves as a platform for addressing issues and challenges unique to each of the seven regions in the state, as well as our metro health department partners. These gatherings provide invaluable insights into the concerns and obstacles faced by employees statewide.

Public Health Storytelling served as the theme for the 2024 Roadshow. Storytelling activities were implemented that began with individual storytelling and grew into group storytelling activities that focused on the public health issues they are addressing in their communities. This provided an opportunity for team building, learning, and providing a vision for where they want to go regarding these issues. The final part of the roadshow incorporates a “speed-networking” session where local and regional attendees got to spend time with each Central Office based section and learn about who they are, what they do, and how they can be a resource to the work taking place at the local level.

TN Department of Human Resources State Enterprise Exit Survey: Health

Tennessee State Enterprise Exit Survey results for the Tennessee Department of Health was conducted from March 2022 through February 2023. This survey identified workforce-related opportunities to address turnover and improve retention. For Health, there were 98 eligible separations and 46 respondents, with 6 identified as working within Family Health and Wellness. The top reasons for leaving included low pay, supervisory issues, and no room for career development. Survey respondents indicated inadequate onboarding and training, lack of leadership support, and feeling unappreciated and a lack of recognition.

 

FHW Employee Engagement Survey

 

The purpose of the survey was to gather feedback from all Family Health and Wellness (FHW) members and identify the strengths and weaknesses within the division. Some of the notable results from the survey are that 90% of respondents reported being satisfied/extremely satisfied with employment at FHW. 94% of respondents agree/strongly agree they have the proper materials to complete their work and 91% stated they agreed/strongly agree they have opportunities to perform best at their work. Some areas for improvement within the division are fostering positive leadership, cultivating growth within the division as well as promoting staff connection.

 

Health Literacy

 

The division of Population Health Assessment recently released a Health Literacy Fact Sheet. Some of the main findings from this report show that few Tennessee adults (6%) found it difficult to get or understand health information and (7%) understand written information. Difficulty getting health information was the highest among those aged 18-24 (11.8%) and with less than a high school education (8.6%). Health literacy was linked to better health behaviors and less chronic disease. Tennessee adults with difficulty finding information were half as likely to exercise and three times more likely to smoke everyday. Tennessee adults with difficulty getting health information were also less likely to reported having routine screenings within the recommended time frame. Tennessee adults with difficulty getting information were also three times more likely to report having cardiovascular disease and five times more likely to have chronic obstructive pulmonary disease. This social determinant of health is critical to understand and suggestions for improvement include bettering communication and support skills of providers.

 

Fetal Death Report

 

This summer, TDH released its first fetal death data report, covering fetal deaths that occurred from 2017- 2021. Key findings include:

• Over a span of 10 years (2012-2021), the fetal mortality rate decreased 18% from 8.0 to 6.6 per 1,000 live births and fetal deaths, with an average of 567 fetal deaths annually.
• The fetal mortality rate for non-Hispanic Black mothers was 2.1 times higher than the Healthy People 2030 Target. Other races/ethnicities met and exceeded the 2030 Target.
• The fetal mortality rate for pregnant women without any prenatal care was 5.3 times the rate for those with any prenatal care.
• The fetal mortality rate was higher among those who smoke during pregnancy (7.9 vs. 6.1)

 

Birth Defects Dashboard

 

• The Birth Defects Program created the Tennessee Birth Defects Dashboard to allow users to explore birth defects data in greater granularity.
• The interactive data dashboard allows users to filter data by county, region, and type of birth defect and also includes information related to social determinants of health and maternal health risk factors.
• The dashboard has been presented in National Birth Defects Prevention Network (NBDPN) meetings and other states including New York and Massachusetts are using it as a template to develop their own interactive data dashboards.

 

Advisory Councils

 

There are specific advisory councils required by state law:

• Traumatic Brain Injury Advisory Council continues to meet quarterly and has nine members.
• Genetic Advisory Committee meets three times a year and has 18 members. Membership includes the directors of the genetics and hemoglobinopathies centers, subspecialists, and a consumer representative.
• Perinatal Advisory Committee meets three times a year and has 21 members. Membership includes co-directors of the five regional perinatal centers, other neonatal and obstetric providers, and a consumer representative.
• Doula Services Advisory Committee – this is a three-year project (July 1, 2023 – July 1, 2026) that was legislatively mandated. As enacted, creates the doula services advisory committee, attached to the department for administrative purposes, to advise the department by establishing core competencies and standards for the provision of doula services in this state, and recommend reimbursement rates and fee schedules for TennCare reimbursement for doula services. - Amends TCA Title 4; Title 8; Title 56; Title 63 and Title 71.
• Children’s Special Services Advisory Committee is required by law TCA 68-12-101-112. The advisory committee meets biannually. The committee is composed of one (1) family consumer advocate, one (1) family nurse practitioner and 4 medical doctors that have different specialties.
• The Child Fatality Review State Team is backed by TCA § 63-42-101-105. Legislation requires the group to convene a minimum of once annually, however meetings occur on a quarterly basis.

 

Other work groups or task forces also support MCH/Title V work to engage with a multidisciplinary team of partners. Examples of these groups include:

• Maternal Health Task Force
• Lead Advisory Committee
• Birth Defects
• Hearing Advisory Committee
• Suicide Prevention Advisory Group
• Injury Prevention Coalition
• Health Disparities Advisory Group
• Home Visiting Leadership Alliance
• TN Young Child Wellness Council
• Early Hearing Detection and Intervention advisory committee for the Newborn Hearing Follow-up Program.
• TCAPES (Tennessee Child and Adolescent Psychiatry Education and Support) Advisory Committee

 

Changes in Health Status and Needs of the State’s MCH Population

 

National Outcome and Performance Measures

There are 9 Outcome and Performance Measures with significant improvement in Tennessee since baseline from data reported in the Application/Annual Report Year: 2024/2022 Federally Available Document:

 

• Neonatal abstinence syndrome decreased from 16.9 per 1,000 birth hospitalizations in 2015 Q1-3 to 9.6 in 2020 (NOM-11)
• HPV vaccination increased from 48.7% among adolescents 13-17 in 2015 to 75.3% in 2021 (NOM 22.3)
• Tdap vaccination increased from 79.7% among adolescents 13-17 in 2015 to 92.0% in 2021 (NOM 22.4)
• Meningitis vaccination increased from 76.7% among adolescents 13-17 in 2015 to 88.1% in 2021 (NOM-22.5)
• Teen births decreased from 30.6 per 1,000 among 15–19-year-olds in 2015 to 21.5 per 1,000 in 2021 (NOM-23)
• Low-risk cesarean delivery decreased from 27.6% in 2015 to 26.6% in 2021 (NPM-2)
• Developmental screening among children, ages 9 through 35 months increased from 26.2% in 2016 to 44.1% in 2020-2021 (NPM-6)
• Transition to adult care among CYSHCN aged 12-17 increased from 19.2% in 2016 to 24.2% in 2020-2021 (NPM-12)
• Smoking in pregnancy decreased from 14.3% in 2015 to 9.1% in 2021 (NPM-14.1)

 

There are 8 Title V Outcome and Performance Measures with significant worsening since baseline:

• Early term birth increased from 26.6% in 2015 to 29.7% in 2021 (NOM-6)
• Tooth decay/cavities among children 1-17 years increased from 8.9% in 2016 to 12.8% in 2020-2021 (NOM-14).
• Adolescent mortality among 10–19-year-olds increased from 39.8 per 100,000 in 2015 to 54.9 per 100,000 in 2021 (NOM-16.1)
• Adolescent motor vehicle death among 15–19-year-olds increased from 15.1 per 100,000 in 2014-2016 to 20.6 in 2019-202 (NOM 16.2)
• Flu vaccination among children 6 months to 17 years decreased from 61.8% in 2015-16 to 54.2% in 2021-2022 (NOM-22.2)
• Child injury hospitalization among children 0 through 9 years increased from 109.3 per 100,000 in 2015 Q1-3 to 130.3 in 2020 (NPM-7.1)
• Adolescent injury hospitalization among children 10 through 19 years increased from 191.2 per 100,000 in 2015 Q1-3 to 233.1 in 2020 (NPM-7.2)
• Adolescent physical activity among children 12 through 17 years decreased from 22.4% in 2016 to 13.8% in 2020-2021 (NPM-8.2)

 

Overall

The 2024 Vanderbilt Child Health poll aimed to gather insights from Tennessee parents regarding their children. A representative sample of 1,025 parents in the state were surveyed in Fall 2023. The top five concerns parents had for kids were: 1) education and school quality, 2) bullying, including cyberbullying, 3) mental health and suicide, 4) school gun violence, and 5) drug and alcohol use. Parents’ report of their child’s overall wellbeing has declined from 87.1% in 2019 to 82% in 2023.

 

Emerging Issues

 

Food Insecurity

Over 40% of Tennessee families reported low or very low food security in 2023, according to the Vanderbilt Child Health Poll. There were both racial and geographic disparities with 49% of black families reporting food insecurity compared to 40% of white families and 49% of families in west Tennessee compared to 34% of families in middle Tennessee. Over 70% of families have changed their spending habits due to an increase in food prices, with 25%% of those parents skipping meals.

 

Child Homicide Deaths

In 2021, 67 Tennessee children died of homicide, a rate of 4.4 deaths per 100,000 children: the second-highest number and rate over the past five years. Tennessee consistently is above the national rate of 3.0 per 100,000 from 2021. Firearms were used in 86% of homicide deaths among children. Additionally, child homicide deaths persist in disproportionately impacting Black children.

 

Mental Health

Mental health continues to be a critical issue in Tennessee. According to the Vanderbilt Child Health poll, ~1 in 3 parents reported a mental health diagnosis for their children, with 17% diagnosed with anxiety and 10% with depression in 2023. The Tennessee Youth Risk Behavior Survey 2021 results support this, as they found 42.2% of high school students felt sad or helpless almost every day for greater or equal to 2 weeks in a row so that they stopped doing some usual activities; this represents a significant increase from 2015 (28.0%). Additionally in 2021, 22.8% of high school students seriously considered suicide, which represents an increasing trend since 2011, when the percentage was 14.7%.

 

Pregnancy-Related Mortality

In 2021, 134 women in Tennessee died during pregnancy or within the year after pregnancy. There were 53 pregnancy-related deaths, which translates to a pregnancy-related mortality ratio of 64.9 deaths per 100,000 live births, almost two times the 2017 – 2020. The three leading causes were COVID-19, cardiovascular disease, and substance use disorder. Out of the pregnancy related deaths, seven in ten (70%) pregnancy associated deaths were deemed preventable. The burden of pregnancy related deaths was higher for Non-Hispanic Black women who were 2.3 times a likely to die as white women.

 

Drug Overdoses and Opioid Prescriptions

From the Tennessee Hospital Discharge Data System, in 2022, there were 7,549 nonfatal overdoses in the state among women aged 15-44 years (defined through the International Classification of Diseases, Version 10, Clinical Modification Codes T36-50), an increase of 9.0% from 2021. In 2022, there were 1,214 overdose deaths among females which was a slight decrease by 3% compared to 2021.

 

Home Births

In 2023 provisional birth data, 1.9% of all births were intended home births (N=1512), a significant increase from 2017, when intended home births comprised 0.9% of all births. There were 737 more intended home births in 2022 compared to 2017. From 2012 to 2022, nearly half (46.9%) of home births were midwife-attended, 31.8% were nurse-attended, 7.4% were physician-attended, and 13.9% were unattended. Unattended home births nearly doubled from 2.13% of all births in 2012 to 4.15% in 2022. Looking across the state, public health regions varied from 0.7% to 4.3% in births that were intended home births. Home birth also significantly increased in both urban and rural counties, with Tennessee large fringe metro areas having the highest increase in home births, from 0.08% of all births in 2012 to 0.22% in 2022. To ensure timely access to newborn screening for these home births, TDH added functionality to the Newborn Dried Blood Spot Screening Dashboard (tn.gov) to track screening for home births.

 

Electronic Vapor Products

In 2021 Tennessee Youth Risk Behavior Survey, 39.5% of high school students reported ever using an electronic vapor product, including e-cigarettes, vapes, vape pens, e-cigars, e-hookahs, hookah pens and mods (such as JUUL, SMOKE, Suorin, Vuse, and blu). While there is no change in trend after controlling for sex, race/ethnicity, and grade since 2015 (41.6%), the outcomes associated with electronic vapor products in adolescents remains a high concern.

 

State Title V Partnerships and Collaborations

 

Tennessee’s MCH/Title V program continues to partner with numerous entities at the federal, state, and local level to serve the legislatively defined MCH populations and to expand the capacity and reach of the state MCH/Title V and CYSHCN programs. Existing partnerships are highlighted within the annual report.

 

One highlight of collaboration this past year has been our Presumptive Eligibility Program collaborating with Federally Qualified Health Centers to meet pregnant women at the place of their prenatal care to ensure they receive timely insurance coverage. The PE Program has established a contract with East Tennessee State University's Johnson City Community Clinic, and they are now enrolling individuals in TennCare. The clinic has reported that this change was a seamless integration to their current workflow and patients have expressed the convenience of enrolling in TennCare and receiving care at the same location.

 

Data Sharing with State Partners

Suicide Data Sharing with Department of Mental Health and Substance Abuse Services. In May 2024, the Tennessee Department of Health (TDH) entered into an interagency data sharing agreement with the Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS). Per the data use agreement, TDH’s Office of Vital Statistics will provide portions of the 2022 Final Death Statistical File, as well as the 2023 and 2024 files at they become available. Additionally, TDMHSAS will provide TDH’s Suicide Prevention Team with monthly crisis center (i.e., 988) utilization data. Finally, TDH and TMHSAS representatives will be coordinating quarterly touchpoint meetings to discuss logistics and analysis of the data provided data per the data use agreement.

 

TennCare Data Sharing with WIC

Tennessee WIC is collaborating with TennCare on a data sharing pilot program to increase WIC participation among eligible pregnant Tennesseans. Contact information of pregnant women enrolled in TennCare is shared with Tennessee WIC to identify individuals enrolled in TennCare and not enrolled in WIC. Tennessee WIC staff will use the information to reach out to those individuals and inform them of their WIC eligibility with the objective of enrolling them in the program.

 

The MCH/Title V CYSHSN program has a staff member responsible for Family/Youth Engagement and Involvement whose primary responsibility is to work with Family Voices to ensure opportunities for family and youth training on patient centered medical homes, transition, and policy/advocacy. In addition, several programs continue to expand their own advisory and family groups to better inform programs and services, including recruitment of regular parent participants in the Perinatal Advisory Committee and Genetics Advisory Committee. Likewise, the Community Health Access and Navigation in Tennessee (CHANT) program has incorporated family engagement to assure that the needs of children and families are being met appropriately.