Section III.C. Needs Assessment Update

 

2022 Needs Assessment Approach

COVID-19 has been a focal point of efforts across all populations in the United States and in North Dakota. Given the impact of this virus on the state’s population, the 2022 needs assessment process involved the utilization of the state’s data around cases, hospitalizations and death and assessing the impact of these changes in 2021 to the state’s maternal and child health (MCH) populations.  We will be discussing the changes in the health, health care access and utilization, and mortality trends of women/mothers, perinatal/infants, and adolescents before and after the COVID-19 pandemic. We will discuss disparity factors that have been identified in 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, and includes MCH as an integral piece of this assessment; hence, some of the elements of this process were included in this assessment around mortality and severe morbidity and hospitalizations. The North Dakota Department of Health (NDDoH) recently conducted a comprehensive family planning needs assessment. While the assessment is required under the terms for Title X federal grant requirements, more importantly, the assessment identifies and documents the need for family planning services in North Dakota by identifying trends and areas of greatest need to help guide delivery of family planning services. The Family Planning Program (FPP) will use the results of this assessment to inform and improve service delivery over the next five years  We have also included relevant results generated from the evaluation of the Title X Family Planning program in the state.  From this evaluation we have included data on births, fertility, pregnancy, behavioral health and substance abuse and data specific to health care access and utilization. With these two main sources of data, we have a complete picture of the health status of the population of mothers and children in North Dakota.

 

North Dakota Family Planning Needs Assessment Elements

Women/Maternal

North Dakota continues to be one of the fastest-growing states in the nation, with over a 15.2 percent population increase between 2010 (672,591) and 2021 (774,948). Population growth has in part been due to an increase in fertility rates. According to 2020 NDDoH Division of Vital Records Data, the fertility rate among women ages 15 to 44 in the state was 77.8 per 1,000 women, substantially higher than the United States fertility rate of 58.3 births per 1,000 women ages 15-44 (National Center for Health Statistics, National Vital Statistics System, Natality; NCHS Data Brief, Number 418, September 2021).

 

While the rate of teen pregnancies in North Dakota (15.5 per 1,000 females 15 to 19 years of age in 2019) is lower than national rates (16.7 per 1,000 females 15 to 19 years of age in 2019), American Indian (AI) teenagers in North Dakota had substantially higher rates than white teenagers.  From 2016 to 2019, AI 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)

 

Most women who gave birth in 2019 received prenatal care, 77.8 percent of women received first-trimester prenatal care, 15.5 percent of women received care in the second trimester and 6.8% of women received late or no prenatal care. AI (44.2%) and Black (65.6%) women in the state were less likely to receive early prenatal care, beginning in the first trimester (1-3 months), compared to their White (84.4%) counterparts (National Center for Health Statistics, final natality data. Retrieved October 21, 2021, from Peristats | March of Dimes).  The graphs below show the results of the 2017 thru 2020 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 Indians women initiated prenatal care in the first trimester compared to Whites.

 

Also, American Indian women, adolescent girl, those in rural areas and the uninsured had a higher percentage of eight or fewer prenatal care visits.  PRAMS data also show a decrease in the number of overall prenatal care visits in 2019 and 2020.

 

 

 

 

 

 

 

 

 

 

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 AI women, adolescent girls, those living in rural areas, and those without health insurance showed a higher percentage of inadequate prenatal care.  The map below shows the percentages of inadequacy 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.

 

 

These counties have been identified as high vulnerability counties (2018 overall SVI score). As of 2020, 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. The table below shows the impact of disparity in the geographic distribution of these three counties, in comparison to the state and the nation.

 

 

 

 

 

 

 

 

North Dakota Title X Disparity Impact Statement: Demographic distribution

Age & Sex     Females Under 18 60 and over	United States (331,449,281)	North Dakota (762,062)	Sioux County* (4,230)	Benson County* (6,832)	Rolette County* (14,176)
	50.8% 22.3% 16.5%	48.8% 24.8% 21.9%	49.9% 35.8% 8.5%	49.1% 35.2% 14.4%	50.1% 33.7% 12.2%
Race & Ethnicity White (not Hispanic or Latino) American Indian Black or African American Hispanic or Latino Two or more races	76.3%   1.3% 13.4%   18.5% 10.2%	88.2%   6.0% 3.9%   4.1% 5.4%	13.6%   81.4% 0.7%   5.1% 4.0%	41.6%   55.6% 0.5%   4.1% 2.9%	18.4%   78.0% 0.5%   2.1% 4.3%
Education High School or higher 25 years+ Bachelor’s degree or higher 25 years+	88.0%   32.1%	92.6%   30.0%	83.7%   15.0%	86.3%   16.2%	87.5%   19.6%
Income & Poverty Median household People living below poverty level Under 18 y/o living below poverty level	$65,712 12.3%   16.8%	$67,402 10.5%   10.9%	$37,133 32.1%   35.4%	$45,709 23.3%   33.9%	$45,296 25.9%   30.1%
Foreign born	13.6%	4.1%	0.2%	0.3%	0.4%
Residential Mobility Move from a different State/abroad	2.4	4.9%	4.4%	2.7%	5.2%
Health Civilian with disability, under 65 years Without Health Care Coverage	8.6%   9.2%	7.2%   6.9%	9.6%   31.6%	12.0%   11.0%	13.5%   25.3%
Language Spoken at home Language other than English at home	21.6%	6.0%	5.3%	7.4%	2.5%

 

 

 

Data Sources:

Small Area Income and Poverty Estimates (SAIPE) 2019

ACS vintage year 2019 (2015-2019)

2020 Census Redistricting Data (Public Law 94-171) Summary File.

 2019 ACS 1-Year Estimates Subject Tables

Note: Estimates are not comparable to other geographic levels due to methodology differences that may exist between different data sources.

*Counties with high level of vulnerability (2018 Overall SVI Score)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

When looking at trends over the last four years, in women who did not receive prenatal care, there was an increase in the proportion of women who did not have care in 2020 (1.3%), compared to 2017 to 2019 (0.6%-0.9%).

 

Nine percent of women of reproductive age (15-49 years) were uninsured in 2019, and 13% were on North Dakota Medicaid. Most women of reproductive age had private health insurance (74%). From 2016 to 2019, there was a slight increase in the percentage of women receiving North Dakota Medicaid (2.4%). 

 

Perinatal/Infant

As of 2019, an estimated 95% of children in the state had health insurance (NSCH). In 2020 state rates for infant mortality were like national averages, 6.0 deaths per 1,000 live births in North Dakota compared to 5.6 deaths per 100,000 live births nationally. For Indigenous populations, infant deaths account for 2.2% of all Indigenous deaths. By contrast, infant deaths associated with all other races in North Dakota represented 0.75% of those races' deaths The rate of low birthweight is slightly better than national rates, six percent in North Dakota, compared to eight percent nationally (https://www.countyhealthrankings.org/sites/default/files/media/document/CHR2020_ND.pdf ). North Dakota is roughly in the middle of state rankings for maternal mortality. In 2018, North Dakota had 20.1 maternal deaths per 100,000 births (NDDoH Division of Vital Records).

 

Adolescent

According to 2019 US Census Bureau population estimates, 23.6% 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 percent of adolescents and 8.5 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 first out of 50 states, with a binge alcohol use rate of 30.6 percent, compared to a low of 16.2 percent 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 percent of North Dakota residents over the age of 12 reported a substance use disorder, compared to the US average of 7.4 percent (https://www.samhsa.gov/data/sites/default/files/reports/rpt32805/2019NSDUHsaeExcelPercents/2019NSDUHsaeExcelPercents/2019NSDUHsaePercents.pdf). The state ranks 12th nationally in suicides rates with 18 suicides per 100,000 (https://www.cdc.gov/nchs/pressroom/sosmap/suicide-mortality/suicide.htm)  and was the 11th leading cause of death in 2020 (https://www.health.nd.gov/sites/www/files/documents/Files/Vital/ff2020.pdf). According to data from 2019-2020, National Survey of Children’s Health (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%*), who were females (38.6%*), and who resided in non-metropolitan statistical area (43.7%) in the state. 

 

State Health Assessment Elements

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

 

Women/Maternal

A total of 664 deaths occurred among women ages 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 ages 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 ages 18 to 55.

 

Perinatal/Infant

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 percent of North Dakota infants lived in rural counties. A slightly higher percentage of infant deaths occurred in rural counties (35 percent).

 

 

 

 

 

 

 

 

 

 

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

 

Infant deaths accounted for 1.9 percent of all American Indian deaths in North Dakota from 2017 through 2020. For all other races in North Dakota, infants comprised 0.75 percent 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 the 10 counties with the highest infant mortality rates were combined, the average rate was nearly four times higher than the average for the 10 counties with the lowest infant mortality rates.

 

 

 

 

 

 

 

 

 

 

 

 

Youth (1-19 years old)

Among children, from 2017 through 2020, 413 deaths occurred among North Dakotans ages 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), suicide (47). Race/ethnicity data describes 281 deaths occurred among White children, followed by 73 deaths among AI children, representing a notably higher mortality rate among AI children in the state.

 

 

 

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

 

Hospital discharge data from 2016 to 2018 in children ages 0-17 describe 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 AI, 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 Statewide Health Assessment, will be instrumental in guiding statewide activities and informing MCH programs.

 

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

In wake of the COVID-19 pandemic, the OSE 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.  The data included in this report are from cases reported as of April 5, 2022 (since March 2020). 

 

Women/Maternal

The COVID-19 pandemic has directly and indirectly affected maternal and child health differently by race, age, and geographic region (urban vs. rural). According to the 2017-2019 North Dakota Pregnancy Risk Assessment Monitoring System (PRAMS) data, 69.2% of women (43.8% of 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 April 5, 2022, 26.5% of the total confirmed COVID-19 cases were among women ages 15 to 44 and of them 3.6% were pregnant women. Case, Hospitalization and Death Data are shown in the figure below. The rate of COVID-19 cases in the state in women 15-44 years of age for that period is 404.30 cases per 1,000 population.  For pregnant women (15-44 years of age) the rate of cases is 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 Women (15-45 years old)

 

 

 

Covid-19 Trends among pregnant women (15-45 years old)

 

The tables below are exhibiting the rates of cases, hospitalizations, and deaths per 1,000 population in women of ages 15 to 44 by race and ethnicity. The proportion of cases, hospitalizations and deaths were significantly high in the AI population than any other race. 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.

 

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

Race	Cases per 1000 population		Hospitalizations per 1000 population		Deaths per 1000 population
White	322.30		2.54		0.05
American Indian	365.45		8.74		0.59
Black	300.54		6.99		0.14
Asian	235.78		4.74		0
Ethnicity		Cases per 1000 population		Hospitalizations per 1000 population		Deaths per 1000 population
Hispanic or Latino		121.89		1.13		0.05
Not Hispanic or Latino		121.86		1.07		0.13

 

The tables below are exhibiting the rates of cases, hospitalizations, and deaths per 1000 population in pregnant women of age 15 to 44 by race and ethnicity. The proportion of cases and hospitalizations were high in Black population than any other race. 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 1,000 pregnant women of ages 15 to 44 by race and ethnicity as April 5, 2022

Race	Cases per 1,000 population	Hospitalizations per 1,000 population	Deaths per 1,000 population
White	12.09	0.37	0.01
American Indian	13.81	0.49	0
Black	16.54	0.99	0
Asian	7.24	0.75	0

 

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

 

 

 

Percent of COVID-19 hospitalizations and deaths with comorbidities in all women ages 15-44 as April 5, 2022:

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

 

 

 

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

 

From the three age groups displayed on the left, 40-49 age group women are fully vaccinated by 61.3% and 52% got their booster dose, which are higher than the other groups displayed.

 

 

Vaccination status percentages for women ages 19 to 49 as of April 5, 2022

 

 

 

 

 

 

 

 

 

 

 

 

Maternal Mortality

 

 

Maternal Mortality has been on an upward trend since 2015.  In 2020, the North Dakota maternal mortality rate was 88.7% higher than it was in 2015. At the same time, pregnancy and birth rates have continuously been declining.  In such a case where fewer and fewer women are becoming mothers, North Dakota should be able to put more resources to work on keeping mothers alive. While COVID-19 likely influenced maternal mortality, the general upward trend had been established previously. While there was a dip in 2018, the percentage change year over year exhibited from 2019 to 2020 is more in line with the previously established trends.

 

North Dakota trends in pregnancy and birth rates, 2015 to 2020

Year	2015	2016	2017	2018	2019	2020
Pregnancy Rate	18.07	18.28	17.30	17.13	17.00	16.27
Birth Rate	16.75	16.90	15.97	15.80	15.53	14.94

 

 

 

Children ages 0 to 17 years old

In North Dakota, 45% of confirmed cases among children in the first 12 months of the pandemic were determined to be contracted through household contact. Shared spaces make 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 April 5, 2022, 17.2% of the total confirmed COVID-19 cases were among children ages 0 to 17. Case, Hospitalization and Death Data are shown in the figure below. The rate of Covid-19 cases in the state in children ages 0 to 17 years of age for that period is 222.05 cases per 1,000 population.  The hospitalization and mortality rates for children ages 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)

 

The tables below are exhibiting the rate of cases, hospitalizations, and deaths per 1,000 population in children ages 0 to 17 by race and ethnicity. Severe outcomes and death caused by COVID-19 were relatively rare in North Dakota children. No deaths were registered in the non-Hispanic category even the cases and hospitalizations are registered higher than the Hispanic category.        

 

 

 

 

 

Rates of COVID-19 Cases, Hospitalizations and, Deaths per 1000 children of ages 0 to 17 by race and ethnicity as April 5, 2022                                  

Race	Cases per 1,000 population	Hospitalizations per 1,000 population	Deaths per 1,000 population
White	157.80	0.73	0.01
American Indian	202.27	1.59	0.06
Black	124.66	1.12	0
Asian	136.81	0.75	0

 

Ethnicity	Cases per 1,000 population	Hospitalizations per 1,000 population	Deaths per 1,000 population
Hispanic or Latino	53.09	0.23	0.07
Not Hispanic or Latino	55.06	0.25	0
Ethnicity	Cases per 1,000 population	Hospitalizations per 1,000 population	Deaths per 1,000 population
Hispanic or Latino	17.35	0.27	0
Not Hispanic or Latino	12.83	0.38	0

 

The plots below display the percentage of Hospitalization and Deaths in this population specified 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 Ages 0-17 as April 5, 2022:

 

 

The coverage rate in children from 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 April 5, 2022

 

 

 

 

 

 

 

Children with Special Health Care Needs

According to data from 2019 to 2020 National Survey of Children with Special Health Care Needs (NSCH) in North Dakota, 12.7% 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, 48.6% had continuous and adequate insurance, only 42% had medical home and 76.5 % were involved in shared decision-making if it was needed. Among CSHCN, only 10.6% with 2 or more ACE’s, 2.6% of children ages 0 through 5, 8.8% of children ages12 through 17, 7.7% of children whose parents whose household income-poverty ratio at 100%-199%, 6.3%*with household structure comprising of single parent, 9.2% males, and 6.1% residing in non- metropolitan statistical area of North Dakota received care in a well-functioning system.

 

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 ACE’s, 26.5% were females, and only 12.1% were residing in central North Dakota city received services necessary to make transitions to adulthood.

 

Conclusions 

Health disparities among AI populations, adolescent girl, those in rural areas and the uninsured rural are evident across nearly all indicators. COVID-19 will continue to be 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 Maternal and Child Health Services.