Section III.C. Needs Assessment Update

 

2023 Needs Assessment Approach

The 2023 needs assessment process explored changes in the health, health care access and utilization, and mortality trends of women/mothers, perinatal/infants, children, and adolescents over the last five years in North Dakota. This assessment aided in the identification of health disparities impacting the state, such as age, geographic location (urban vs. rural), race and economic status.   

 

A state health assessment was conducted by North Dakota State University, Center for Social Research, which included Maternal and Child Health (MCH) as an integral piece of this assessment; hence, some of the elements encompassed in this assessment included mortality, severe morbidity, and hospitalizations. In 2022, the North Dakota Department of Health and Human Services (NDDHHS) conducted a comprehensive Family Planning Needs Assessment. While the assessment is required under the terms for Title X federal grant requirements, this is a valuable assessment as it supports the need for family planning services in North Dakota by identifying trends and areas of greatest need to help guide the delivery of family planning services. The Family Planning program staff utilize the results of this assessment to inform and improve service delivery. Data below includes relevant information generated from the evaluation of the Title X Family Planning program in the state, including data on births, fertility, pregnancy, behavioral health and substance abuse, and data specific to health care access and utilization. This section also includes conclusions from the North Dakota Pregnancy Risk Assessment Monitoring System (PRAMS) from 2017 to 2021. PRAMS is a collaborative surveillance project of the Centers for Disease Control and Prevention (CDC) and the NDDHHS. With these core sources of data, we have a better picture of the health status of the population of mothers and children in North Dakota.

 

Women’s and Maternal Health

North Dakota continues to be one of the fastest-growing states in the nation, with over a 15.9% population increase between 2010 (672,591) and 2021 (779,261).  Population growth has in part been due to an increase in fertility rates. According to 2021 NDDHHS Vital Records data, the fertility rate among women ages 15 to 44 in the state was 66.68 per 1,000 women, substantially higher than the United States provisional fertility rate of 56.1 births per 1,000 women aged 15-44 (National Center for Health Statistics, National Vital Statistics System, Births: Provisional data for 2022; NVSS Vital Statistics Rapid Release, Report number 28, June 2023). 

 

Birth rates among American Indians are higher than among White (16.99 vs. 12.00; Centers for Disease Control, WONDER, 2021).  In addition, the rate of teen pregnancies in North Dakota (16.64 per 1,000 females 15 to 19 years of age in 2021) is higher than the national rate (13.9 per 1,000 females 15 to 19 years of age in 2021). Moreover, Native American teenagers in North Dakota had substantially higher rates than white teenagers. From 2016 to 2020, Native American teen pregnancies were almost four times that of White teenagers, 46 teenage births per 1,000 live births, compared to ten teenage births per 1,000 live births, respectively (Centers for Disease Control, WONDER).

 

Of all live births in North Dakota during 2018-2020 (average), 3.4% were to women under the age of 20, 52.9% were to women ages 20-29, 41.7% were to women ages 30-39, and 2.0% were to women ages 40 and older. Babies delivered to younger and older women are often at increased risk of poor birth outcomes, including prematurity, low birthweight, and infant mortality. 

 

Most women who gave birth in 2021 received prenatal care, 81.7% of women received first-trimester prenatal care, 12.6 percent of women received care in the second trimester and 5.7% of women received late or no prenatal care.

 

 

 

In North Dakota during 2019-2021 (average), White (85.3%) mothers had the highest rates of early prenatal care, followed by Asian/Pacific Islanders (74.5%), Blacks (67.3%) and American Indian/Alaska Natives (45.2%) (National Center for Health Statistics, final natality data. Retrieved June 8, 2023, from Peristats | March of Dimes). The graphs below show the results of the 2017 through 2021 Pregnancy Risk Assessment Monitoring System (PRAMS). Differences were observed in the proportion of women who did not initiate prenatal care during the first trimester by race.  A lower percentage of American Indian women initiated prenatal care in the first trimester compared to White women. Lastly, American Indian women, adolescent girls, women in rural areas, and the uninsured had a higher percentage of eight or fewer prenatal care visits.

 

Prenatal care initiation in the first trimester by maternal race (ND PRAMS: 2017-2021)

 

Number of prenatal care visits by maternal race (ND PRAMS: 2017-2021)

 

 

 

Number of prenatal care visits by urban/rural (ND PRAMS: 2017-2021)

 

 

 

 

 

 

 

 

 

Number of prenatal care visits by insurance status (ND PRAMS: 2017-2021)

 

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. The maps below show the percentages of inadequacy and adequacy by county. Sioux*, Rolette*, and Benson* counties show the highest percentages in the inadequate category compared to the rest of the counties in the state.

 

Adequacy Index: Inadequate (ND PRAMS 2017-2021)

 

These counties have been identified as high vulnerability counties (2018 overall SVI score). As of 2022, 50 of the 53 North Dakota counties are partially or fully designated as Health Professional Shortage Area and/or Medically Underserved areas. The same is observed for the state's dental health and mental health. 

 

 

 

 

In North Dakota, 77.4% of counties are maternity care deserts. In addition, 7.5% of counties have low or moderate access to care.

 

 

Adequacy Index: Adequate (ND PRAMS 2017-2021)

Prenatal care adequacy by maternal race (ND PRAMS 2017-2021)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prenatal care adequacy by urban/rural (ND PRAMS 2017-2021)

Prenatal care adequacy by Age (ND PRAMS 2017-2021, combined)

 

 

 

Eight percent of women of reproductive age (15-44 years) were uninsured in 2021, and 24.6% were on North Dakota Medicaid at the time of birth (2021). From 2016 to 2019, there was a slight increase in the percentage of women receiving North Dakota Medicaid (2.4%). 

 

 

From 2017 to 2020, in those women with Medicaid, there is a trend of decreasing counts of women with adequate prenatal care (Kotelchuck Index=3).

 

From 2017 to 2020, in those women with Medicaid, there is a trend of decreasing counts of women with a postpartum checkup for themselves.

 

 

 

 

 

From 2017 to 2020, except for 2018, for those women on Medicaid, there is a decreasing trend in the number of women who did not begin prenatal care in the first trimester of pregnancy.

 

 

 

 

 

 

To analyze trends in mortality and severe morbidity in the MCH population, the Special Projects & Health Analytics Unit in Health Statistics and Performance (HSP) creates data dashboards to summarize vital records and hospital discharge data in the efforts to visualize key findings of the statewide health assessment.

 

A total of 664 deaths occurred among women aged 20-49 in North Dakota from 2017 through 2020. The most frequently reported causes were categorized as other disease (161), accident or injury (124), cancer (101), and suicide (68). Of this total, 11 women were pregnant at the time of death, and an additional 11 were pregnant within 1 year of death.

 

Hospital discharge data indicates that 41,456 hospitalizations among women aged 18 to 55 occurred from 2016 through 2018. The most common services were obstetrics, general medicine, and general surgery with an average length of stay of 3.2 days. The average treatment cost of inpatient services for this population was over $19,000 and, in total, over $835 million was spent on inpatient treatment costs of women aged 18 to 55.

 

Maternal Mortality

 

 

Maternal Mortality has been on an upward trend since 2015.  In 2020, the North Dakota maternal mortality rate was 8.7%. At the same time, pregnancy and birth rates have continuously been declining.

 

 

 

 

 

 

North Dakota trends in pregnancy and birth rates, 2015 to 2021

 

 

Perinatal and Infant Health

According to the results of the 2020-2021 (combined data) National Survey of Children's Health (NSCH), 93.0% (92.9% Nationwide) of children in the state had health insurance (Child and Adolescent Health Measurement Initiative.  2020-2021 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). Retrieved [06/06/23] from www.childhealthdata.org. An estimated 60.3% of children in the state had continuous and adequate health insurance for child’s health needs. 

 

The low birthweight rate in North Dakota is slightly lower than national rate. The low birthweight rate is 7% in North Dakota, compared to 8% nationally (2021 County Health Rankings, https://www.countyhealthrankings.org/explore-health-rankings/north-dakota/data-and-resources). North Dakota is roughly in the middle of state rankings for maternal mortality. Between 2011 and 2021, the rate of infants born low birthweight in North Dakota declined more than 1%.

 

In 2020 state rates for infant mortality were comparable to the national averages, 5.5 deaths per 1,000 live births in North Dakota compared to 5.4 deaths per 1,000 live births nationally (https://wonder.cdc.gov/). For Indigenous populations, infant deaths account for 2.2% of all Indigenous deaths. In contrast, infant deaths associated with all other races in North Dakota represented 0.75% of those races' deaths. 

 

The top five primary causes of death for infants from 2017 through 2020 were perinatal, congenital anomalies, SIDS, accidents, and heart diseases collectively, representing 80 percent of all causes of death among infants.

 

 

Top primary causes of death for infants: North Dakota 2017-2020

 

From 2017 through 2019, 29% of North Dakota infants lived in rural counties. A slightly higher percentage of infant deaths occurred in rural counties (35%).

 

 

North Dakota infant deaths (%) by urban and rural counties: 2017-2019

 

Infant deaths accounted for 1.9% of all American Indian deaths in North Dakota from 2017 through 2020. For all other races in North Dakota, infants comprised 0.75% of all deaths.

 

North Dakota infant deaths (%) by Race: 2017-2020

 

 

 

 

From 2017 through 2020, 32 out of North Dakota’s 53 counties had an infant death. When combining the 10 counties with the highest infant mortality rates, the average rate was nearly four times higher than the average for the 10 counties with the lowest infant mortality rates.

 

Child Health

Among children, from 2017 through 2020, 413 deaths occurred among North Dakotans aged 0 to 19 years old. Of these, 59% occurred among male children.

 

 

The underlying cause of death for this age group were most frequently categorized as other diseases (210), accident or injury (74), and suicide (47). Race/ethnicity data describes 281 deaths occurred among White children, followed by 73 deaths among American Indian children, representing a notably higher mortality rate among American Indian children in the state.

 

 

 

 

Rural counties accounted for 30% of the state’s youth population but had 44% of youth deaths in the state.

 

Hospital discharge data from 2016 to 2018 in children aged 0-17 demonstrate over 32,000 inpatient hospitalizations, most frequently utilizing newborn, neonatal, and general medical services. The average length of stay for North Dakota children during this time was 3.8 days. The average cost of treatment for inpatient hospitalizations among children was $13,800 with a total inpatient expenditure of over $445 million from 2016 through 2018.

 

 

 

 

Health and income disparities among Native American adolescent’s populations and those residing in rural areas are evident across nearly all indicators. These preliminary findings from both assessments, Title X, Family Planning Needs Assessment and the Statewide Health Assessment will be instrumental in guiding statewide activities and informing MCH programs.

 

Children with Special Health Care Needs

According to data from 2020 to 2021 National Survey of Children with Special Health Care Needs (NSCH) in North Dakota, 13.7% percent of children with special health care needs (CSHCN), ages 0 through 17, received care in a well-functioning system compared to 14.4% nationally. Among the components of a well-functioning system, only 27.5% of CSHCN received transition among adolescents, 86.4% had ease to access, 68.3% had preventive medical and dental care, and 48.6% had continuous and adequate insurance. Furthermore, only 42% had medical home and 76.5 % were involved in shared decision-making if it was needed.

According to data from 2019 to 2020 NSCH, in North Dakota, 22.5% of adolescents with special health care needs, ages 12 through 17, received services necessary to make transitions to adult health care compared to 26.1% CSHCN nationally. Among Non-CSHCN, 17.6% in North Dakota received services necessary to make transitions to adult health care compared to 26.6% nationally. Among the components for transition for CSHCN receiving services necessary to make transitions to adult health care: 51.3% of CSHCN received time alone with provider, 66.7% of the providers actively worked with the child, and only 20.3% received anticipatory guidance in North Dakota.

 

Among adolescents with special health care needs, ages 12 through 17 receiving services necessary to make transitions in North Dakota, 28.9% of children had experienced two or more Adverse Childhood Experiences, 26.5% were females, and only 12.1% were residing in a central North Dakota city rand received services necessary to make transitions to adulthood.

 

Adolescent Health

According to the 2022 US Census Bureau population estimates, 24.0% of the population in North Dakota is under eighteen years of age. 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 15% of adolescents and 8.5% 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 first out of 50 states, with a binge alcohol use rate of 30.6%, compared to a low of 16.2% 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, 8.5% of North Dakota residents over the age of 12 reported a substance use disorder, compared to the US average of 7.4% (2018-2019 National Survey on Drug Use and Health: Model-Based Prevalence Estimates (50 States and the District of Columbia) (samhsa.gov).  North Dakota ranks 12th nationally in suicides rates with 18 suicides per 100,000 (NVSS - National Vital Statistics System Homepage (cdc.gov)) and was the 11th leading cause of death in 2020 (NDDoH, Division of Vital Records, ff2020.pdf (nd.gov)). According to data from 2019-2020, NSCH in North Dakota, 49% of children, ages 3 through 17, with a mental/behavioral condition received treatment or counseling compared to 52.3%, implying the need for mental/behavioral condition treatment or counseling. Children, ages 3 through 17 who received treatment or counseling were of ages 6 through 11 (38.3%), were in household income-poverty ratio 200%-399% (44.1%), were household structure of single parent (48.4%), were females (38.6%), and resided in a non-metropolitan statistical area (43.7%) in the state. 

 

The impact of the COVID-19 pandemic on women/maternal and child health

In wake of the COVID-19 pandemic, the Office of the State Epidemiologist uses data collected during case investigation and contact tracing activities to analyze COVID-19 trends among North Dakota population. The following data are from a summary of trends in COVID-19 data on the population of women/maternal and children ages 0-17 years in the state of North Dakota as April 5, 2022 (since March 2020).  This 2023 needs assessment included the most recent data as of June 5, 2023.  Data on pregnant women and comorbidities were discontinued at some point since the original report (April 5, 2022).

 

Women/Maternal

The COVID-19 pandemic directly and indirectly affected maternal and child health differently by race, age, and geographic region (urban vs. rural).  North Dakota has been experiencing substantial declines in birth numbers since the post-pandemic period. North Dakota saw a substantial increase in March 2021, followed by a decrease in births in 2022.  Live births decreased in 2022 in most age groups, except 40-44. The decline was most substantial in women aged 20-24.  During the post pandemic year (2021), a substantial increase in the number of American Indian women live births was observed, while the opposite was observed in women of other races.

According to the 2017-2020 North Dakota PRAMS data, 69.2% of women (43.8% of American Indian (AI) women, 75.5% of White women, and 47.8% of women of other races) reported having a “routine” check up in the 12 months prior to becoming pregnant.  In 2020, this number decreased to 66.2% (36.7% of AI women, 73.9% of White women, and 39.3% women of other races).  The same was observed for mothers residing in a rural geographic area, compared to urban and in teens mom compared to non-teen moms, as described above. 

As of June 5, 2023, 50.0% of the total confirmed COVID-19 cases were among women aged 15 to 44.  Data for pregnant women will no longer be collected as of April 5, 2022.

 

COVID-19 Trends Among Women (15-44 years old) as June 5, 2023

The following data correspond to two years of the COVID-19 pandemic (from March 2020 to April 2022)

As of April 5, 2022, 4% were pregnant women. Data regarding cases, hospitalizations, and deaths as of June 5, 2023, are shown in the figure below. The rate of COVID-19 cases in the state in women 15-44 years of age for April 2022 is 404.30 cases per 1,000 population. For pregnant women (15-44 years of age) the rate of cases was 15.10 per 1,000 population for the same period.  The hospitalization and mortality rates for women 15 to 44 years of age were as follows: 3.95/1,000 population and 0.11/1,00 population, respectively. The hospitalization and mortality rates for pregnant women 15 to 44 years of age were as follows: 0.53/1,000 population and 0.01/1,00 population, respectively. 

 

COVID-19 Trends among pregnant women (15-45 years old) as April 5, 2022*

* Data for pregnant women will no longer be collected as of + April 5, 2022.

 

 

 

 

 

The tables below are exhibiting the rates of cases, hospitalizations, and deaths per 1,000 population in women of age 15 to 44 by race and ethnicity as of June 5, 2023. The proportion of cases, hospitalizations and deaths were higher in the American Indian population than any other race. As of April 5, 2022, proportion of deaths in non-Hispanic or non-Latino were a bit higher than the Hispanic or Latino even though the case rate and hospitalization rate were almost the same in both groups.  Data for Hispanic/Latino will no longer be collected as of  +  April 5, 2022.

 

Rates of COVID-19 Cases, Hospitalizations and, Deaths per 1000 women of age 15 to 44 by race as of June 5, 2023

 

The table below exhibits the rate of cases, hospitalizations, and deaths per 1,000 population in pregnant women of age 15 to 44 by race and ethnicity. The proportion of cases and hospitalizations were higher in Black population than any other race. The proportion of cases and hospitalizations in Hispanic or Latino were higher than the non-Hispanic or non-Latino group.

 

Rates of COVID-19 Cases, Hospitalizations and, Deaths per 1000 pregnant women of age 15 to 44 by race and ethnicity as of April 5, 2022*

 

*Data for pregnant women will no longer be collected as of  +  April 5, 2022.

 

The plots below display the percentage of hospitalizations and deaths in specified underlying conditions. Underlying conditions are self-reported by cases, resulting in the reported values below likely being underestimated. Among women aged 15-44, 38.5% recorded deaths had cardiovascular diseases and 15.4% had diabetes.

 

Percent of COVID-19 hospitalizations & deaths with comorbidities* in all women aged 15-44 as of April 5, 2022

*Data of comorbidities will no longer be collected as of  +  April 5, 2022.

Most hospitalized COVID-19 cases in pregnant women (15 to 44 years old) had other chronic diseases and diabetes. There were no reported deaths that had the underlying conditions listed below.

Percent of COVID-19 hospitalizations with comorbidities in pregnant Women Aged 15-44 as of April 5, 2022*

* Data for pregnant women will no longer be collected as of +  April 5, 2022.

 

 

 

 

From the three age groups displayed, the 40-49 age group of women are fully vaccinated by 61.3% and 13.8% received the bivalent dose, which is higher than the other age groups displayed.

 

 

Vaccination status percentages for women ages 19 to 49 as of June 5, 2023

 

 

Children aged 0 to 17 years old

In North Dakota, 45% of confirmed COVID-19 cases among children in the first 12 months of the pandemic were determined to be contracted through household contact. Shared spaces made isolation and quarantine within the household difficult, resulting in more frequent exposure and transmission among household members. Further, children had more household contacts than the adult population, with 3.5 and 1.7 average household contacts, respectively, in North Dakota.  As of June 5, 2023, 16.3% of the total confirmed COVID-19 cases were among children aged 0 to 17. Case, hospitalization and death data as June 5, 2023, are shown in the figure below. The rate of COVID-19 cases in the state in children aged 0 to 17 years of age for March 2020 to April 2022 is 222.05 cases per 1,000 population. The hospitalization and mortality rates for children aged 0 to 17 years old were as follows: 0.99/1,000 population and 0.02/1,00 population, respectively. 

 

 

COVID-19 Trends Among Children (0-17 years old) as June 5, 2023

 

 

 

 

 

 

 

The tables below are exhibiting the rate of cases, hospitalizations, and deaths per 1,000 population in children aged 0 to 17 by race and ethnicity as June 5, 2023. Severe outcomes and death caused by COVID-19 were relatively rare in North Dakota children. As of April 5, 2022, no deaths were registered in the non-Hispanic category even though the cases and hospitalizations are registered higher than the Hispanic category.        

 

Rates of COVID-19 Cases, Hospitalizations and, Deaths per 1000 children of age 0 to 17 by race and ethnicity as of June 5, 2023

 

 

The plots below display the percentage of hospitalizations and deaths in this population specified by underlying condition. Underlying conditions are self-reported by cases, resulting in the reported values below likely being underestimated. Among hospitalized children, neurological and other chronic diseases were most frequently reported.

 

Percent of Hospitalizations & Deaths with comorbidities in Children Aged 0-17 as April 5, 2022

 

 

The coverage rate in children in the 5-11 age group seems less than in the age group 12-18, as the COVID-19 vaccines were available early for 12 years and older in May 2021 and later in November 2021 for 5 years and older.

 

Vaccination status percentages for children ages 5 to 18 as of June 5, 2023

 

Conclusions 

Health disparities among Native American populations, adolescent girls, those in rural areas, and the uninsured rural populations are evident across nearly all indicators. COVID-19 was a challenge to North Dakota and to the MCH population. The findings from this assessment will help to guide programs and policies to address the state’s need for MCH services.