1. Ongoing needs assessment activities.

MCH Assessment continued with routine analyses of data related to the health and health care of women, infants, and children in the state of Oklahoma. While these efforts are not regularly acknowledged as ongoing needs assessment initiatives, study findings are integrated into the understanding of the populations represented and served, and assist as a baseline for initiating the Five-Year Needs Assessment process. These efforts are constructed around established MCH priorities, grant requirements, project analysis plans, and emerging issues important to MCH target populations.

Collection, management, analysis, and reporting of state-level data are built around MCH surveillance activities for the Pregnancy Risk Assessment Monitoring System (PRAMS), the Oklahoma Toddler Survey (TOTS), and the Youth Risk Behavior Survey (YRBS). These are surveillance projects which are mainstays for Oklahoma MCH. The state’s PRAMS project has been active for more than 30 years, consistently producing high-value data for use in monitoring population health indicators for women and infants. PRAMS continues to collect data but has been facing real and deep challenges to its viability. Response rates have decreased sharply in recent years with Oklahoma not achieving the stated response threshold for receipt of weighted analysis data for use in generalizing to the population at large. The latest PRAMS year for which data collection was completed is 2019; unfortunately, the response rate was insufficient for weighted data. Year 2020 is likely to yield similar findings. MCH Assessment published two reports using PRAMS data in 2020 – Oklahoma Maternal and Child Health Data Review and Breastfeeding Facts at a Glance.

TOTS is Oklahoma’s own follow-back survey to PRAMS respondents, active since 1994. TOTS collects data from PRAMS mothers at the time their children are two-years-old. Alone it is doing fairly well, given the climate of support and participation for observational studies. Yet, this project struggles due to the challenges underway with the PRAMS surveillance system. TOTS response rates are not simply a function of its own response performance. Rather, TOTS response is product of PRAMS response and that achieved during TOTS survey administration. As a result, TOTS response flags, yielding response rates inadequate for data weighting, and compromising our ability to report single year estimates. This has delayed publication of TOTS materials as we wait for data availability to develop multi-year estimates and data products.

With the impact of the coronavirus pandemic in Oklahoma, MCH Assessment elected to delay the administration of the YRBS 2021 from spring to fall, meaning the 2021 questionnaire will not be conducted until October-December months of the 2021-2022 academic year. The 2021 survey includes the 16 questions on adverse childhood experiences. Staff have met regularly to prepare for this surveillance activity. YRBS publications using the latest cycle data available (2019) were published during 2020, focusing on mental health, unsafe driving, alcohol use, sleep health, nutrition, dating violence, and adolescent suicide. Cycle 2021 data should become available mid-year 2022.

Other assessment and data capacity carried out under the auspices of the State System Development Initiative (SSDI) can be found in section (iii) MCH Data Capacity (b) State Systems Development Initiative (SSDI). The OHCA/MCH Medicaid Data Sharing Workgroup developed a linked dataset for births and Medicaid administrative records for calendar year 2018. Combined with previously linked data (2015-2017), the workgroup was able to analyze infant mortality, Native American Medicaid enrollees’ demographic profile, and smoking among mothers receiving Medicaid benefits.

Further, MCH Assessment has participated in the CDC’s COVID-19 Pregnancy Module, which seeks to collect pregnancy and neonate data from women who tested positive for COVID-19 during their pregnancy. Initially, this effort was devoted to contacting by phone pregnant women to complete case report forms with the data then keyed into DCIPHER, the CDC’s Data Collation and Integration for Public Health Event Response platform. Overtime, the volume of cases and the desire for more detailed information led MCH Assessment, in cooperation with CDC, to develop a sample of cases based on priority issues (infant loss, fetal loss, maternal death, ICU admission, neonatal COVID infection) for which medical records will be abstracted with collected data then submitted to CDC for analysis and research publication.

2. Changes in health status and needs of the state’s MCH population

Oklahoma MCH has made no changes to the list of program priorities, remaining focused on the 10 priority needs established with FY2021 grant application. The state continues to implement and maintain programs that address priorities across the lifespan.

Oklahoma has observed improvements in select indicators. The rate of infant mortality decreased slightly (1.4%) from 7.1 infant deaths per 1,000 live births in 2018 to 7.0 in 2019. Since the onset of the Preparing for a Lifetime, It’s Everyone’s Responsibility in 2009, the statewide infant mortality reduction initiative, Oklahoma has seen a decrease of 11.0% in the infant mortality rate. Teen birth rates have continued to decline across all age groups between 2015 and 2019 – ages 15-17 down 30.8% to 11.0 births per 1,000 population, ages 18-19 down 18.8% to 52.1, and ages 15-19 down 21.3% to 27.4.

Preterm birth (PTB), on the other hand, is trending in the wrong direction. In 2014 and 2015, the percentage of births born prior to 37 completed weeks of gestation was 10.3% in each of those years. However, the incidence of PTB has climbed each year from 2015, reaching 11.5% in 2019. Relatedly, low birth weight (LBW) had reached 7.9% of all births in 2015, a year in which Oklahoma outperformed the nation (8.1%), only to rise to 8.3% in 2018, before falling slightly to 8.2% in 2019. Maternal mortality has increased as well, rising from 20.1 maternal deaths per 100,000 live births in 2014-2016 to 23.5 in 2017-2019.

3. Changes in the state’s Title V program capacity

Oklahoma’s Title V programs have experienced staffing changes and reassignments which impacted the ability to carry out its mission and goals. In Perinatal and Reproductive Health, a long serving Advanced Practice Registered Nurse, essential to the work done in the division, retired. The position has been refilled and has assumed the responsibilities. The Child and Adolescent Health Division had a School Health Consultant resign in January 2020. This position is instrumental to the success of the YRBS. It took some months to refill the position which did occur in August 2020. MCH Assessment lost a staff analyst (MCH Medicaid Analyst) in October 2020. Recruitment for the position is ongoing but the vacancy remains. PRAMS and TOTS surveillance experienced staff turnover in 2020, losing two telephone interviewers to resignation and the PRAMS Data Manager, Wanda Thomas, retired in April 2020. While replacement was prolonged, the interviewer positions have been filled with staff undergoing the appropriate training to support these projects. The PRAMS Data Manager position was combined with the TOTS Data Manager position, a position held by Rebekah Rodriguez, a long serving staff member of the MCH Assessment Division. In addition to the above staffing changes, the CSHCN Director took a position in another division at DHS in late May 2021.  The CSHCN Director position remains vacant with the position currently posted for replacement.

The greatest challenge to Title V program capacity has been the impact of the coronavirus pandemic. While there are many duties or responsibilities that can be completed remotely via telework, there are those that cannot, which require in-person collaboration and cooperation. Having staff working remotely for extended months has slowed or delayed projects and trainings. Some work could only be placed on hold until such time that “normal” operations were resumed. Some staff were reassigned temporarily to assist with COVID mitigation efforts, for at least a few days each week. Contributing to additional capacity issues, the entire OSDH moved buildings from October through December, requiring staff to allot time and energy to packing, scanning, sorting and moving offices, many of which had been occupied for decades.

4. Title V partnerships and collaborations

Oklahoma Title V programs have many internal and external relationships that enable or facilitate the successful achievement of goals and objectives. These partnerships and collaborations have been challenged by the coronavirus pandemic given the inability to freely meet in-person. While virtual meetings offer a substitute, they are limited and inhibit or prevent some activities. MCH and CSHCN personnel and their many partners thrive on the interaction gained by working closely together on collaborative projects. Work carried on, but full potential was likely hampered by distancing constraints and staff reassignments to assist with pandemic efforts. With the pandemic abating and the relaxation of guidelines, there will be opportunities to resume meetings with existing partners and to build new connections meaningful to building the data capacity necessary for comprehensive needs assessments of the MCH populations.

5. Operationalizing the Five-Year Needs Assessment process and findings

Oklahoma’s process for preparing the Five-Year Needs Assessment follows a standard stepped process that builds on preceding stages. Initially, MCH leadership and staff hold a series of brainstorming and planning meetings. The early stages focus on clarifying partners and key informants, outlining data collection procedures and constructing collection tools, assigning responsibilities, and formulating a tentative schedule of events. Routine meetings are scheduled to be spaced out over an 18- to 24-month period. As the submission deadline approaches, the frequency of meetings is escalated to assure that milestones are met and to troubleshoot challenges. All members of MCH staff are directly or indirectly involved in the process, with level of participation determined by the roles and responsibilities of staff. Broad oversight of the needs assessment process is provided by MCH leadership (MCH Director and Division Administrative Program Managers), as well as the Director of the CSHCN Program and the Executive Director of the Oklahoma Family Network. Day-to-day coordination of needs assessment activities is carried out by the SSDI Analyst.

6. Changes in organizational structure and leadership

In May 2020, Lance Frye, MD, was appointed by Governor Kevin Stitt as the Interim Commissioner of Health at the Oklahoma State Department of Health. Dr. Frye was appointed after the previous appointee, Gary Cox, was denied confirmation by the Oklahoma Senate. In April 2021, the Senate confirmed Frye as Commissioner of Health. The health agency has experienced several organization changes in the last year. The greater part of health-related services is organized under a single Deputy Commissioner, Keith Reed, MPH, with services aligned under four Assistant Deputy Commissioners for Community Health, Family Health, Personal Health, and Protective Health. Community Health is comprised of Nursing Services, Community Evaluation and Records Support, Emergency Preparedness and Response Service, and the county health departments. Family Health contains MCH, Screening and Special Services, Family Support and Prevention Service, Dental Health, WIC, and SoonerStart. Personal Health is made up of Community Development, Sexual Health and Harm Reduction, Chronic Disease, Injury Prevention, and the Immunization Service. Lastly, Protective Health includes Consumer Health, Long Term Care, Medical Facilities, and Health Resource Development Service.

One of the more important changes in structure has been the relocation of the Public Health Lab from the OSDH in Oklahoma City to Oklahoma State University in Stillwater, Oklahoma, just over an hour north of Oklahoma City. This move was incorporated into the founding of the Oklahoma Pandemic Center for Innovation and Excellence, an institutional named by the Governor’s Office in response to the coronavirus pandemic. These units fall under the Deputy Commissioner of Health Innovation at OSDH.

1. Ongoing needs assessment activities

Assessment staff continued routine analyses of data related to the health and health care of women, infants, and children in the state of Oklahoma. While these efforts are not regularly acknowledged as ongoing needs assessment initiatives, study findings are integrated into the understanding of the populations represented and served, and assist as a baseline for initiating the Five-Year Needs Assessment process. These efforts are constructed around established MCH priorities, grant requirements, project analysis plans, and emerging issues important to MCH target populations.

Collection, management, analysis, and reporting of state-level data are built around MCH surveillance activities for the Pregnancy Risk Assessment Monitoring System (PRAMS), the Oklahoma Toddler Survey (TOTS), and the Youth Risk Behavior Survey (YRBS). These are surveillance projects which are mainstays for Oklahoma MCH. The state’s PRAMS project has been active for more than 30 years, consistently producing high-value data for use in monitoring population health indicators for women and infants. PRAMS continued to collect data but has been facing significant challenges to its viability. Response rates have decreased sharply in recent years with Oklahoma not achieving the stated response threshold for receipt of weighted analysis data for use in generalizing to the population at large. The latest PRAMS year for which data collection was completed is 2020; unfortunately, the response rate was insufficient for weighted data, marking the second consecutive year with this result. Collection cycle for 2021 shows promise with provisional response rates above the 50% threshold currently in use by PRAMS projects. This improvement is driven by the implementation of Amazon gift cards ($10 value) as a reward for survey participation. The PRAMS project applied and received funding ($25,000) from the Council for State and Territorial Epidemiologists to implement a COVID-19 Vaccine Supplement for a portion of the year. With this funding, the gift card value was increased to $20. Data for the 2021 collection cycle should become available in late 2022. MCH Assessment published two reports using PRAMS data in 2021 – Social Support Among Oklahoma Mothers and Preconception Health Disparities and Birth Outcomes among Foreign-Born and Native-Born Hispanic Women in Oklahoma.

TOTS is Oklahoma’s own follow-back survey to PRAMS respondents, active since 1994. TOTS collects data from PRAMS mothers at the time their children are two-years-old. Alone it is doing reasonably well, given the climate of support and participation for observational studies. Yet, this project struggles due to the challenges underway with the PRAMS surveillance system. TOTS response rates are not simply a function of its own response performance. Rather, TOTS response is product of PRAMS response and that achieved during TOTS survey administration. As a result, TOTS response flags, yielding response rates inadequate for data weighting, and compromising our ability to report single year estimates. This has delayed publication of TOTS materials as we wait for data availability to develop multi-year estimates and data products.

With the impact of the coronavirus pandemic in Oklahoma, MCH Assessment elected to delay the administration of the YRBS 2021 from spring to fall school semester. Administration of the survey was successful with nearly all MCH staff taking part. As previously reported, the 2021 survey includes the 16 questions on adverse childhood experiences. Cycle 2021 data should become available mid-year 2022. YRBS publications using the latest cycle data available (2019) were published during 2021, focusing on mental health, unsafe driving, alcohol use, sleep health, nutrition, dating violence, and adolescent suicide.

Other assessment and data capacity carried out under the auspices of the State System Development Initiative (SSDI) can be found in section (iii) MCH Data Capacity (b) State Systems Development Initiative (SSDI). The OHCA/MCH Medicaid Data Sharing Workgroup was on hiatus for 2021 due to the extended period of time for which the Medicaid Analyst position was vacant. The incumbent resigned in late 2020 and while recruitment was underway throughout the year a qualified candidate was not hired in 2021. Fortunately, in July 2022, Assessment was able to hire a master’s trained epidemiologist to fill the position. Rakel Cleveland will assume the position in August. After that time, the project will resume activity of linking and analyzing Medicaid and birth data.

Assessment continued its participation in the CDC’s COVID-19 Pregnancy Module, which seeks to collect pregnancy and neonate data from women who tested positive for COVID-19 during their pregnancy. Initially, this effort was devoted to contacting by phone pregnant women to complete case report forms with the data then keyed into DCIPHER, the CDC’s Data Collation and Integration for Public Health Event Response platform. Overtime, the volume of cases and the desire for more detailed information led Assessment, in cooperation with CDC, to develop a sample of cases based on priority issues (infant loss, fetal loss, maternal death, ICU admission, neonatal COVID infection) for which medical records were abstracted with collected data then submitted to CDC for analysis and research publication.

2. Changes in health status and needs of MCH population

Oklahoma MCH has made no changes to the list of program priorities, remaining focused on the 10 priority needs established with FY2021 grant application. The state continues to implement and maintain programs that address priorities across the lifespan.

The state has observed improvements in select health indicators. The rate of infant mortality decreased sharply, down 14% from 7.0 infant deaths per 1,000 live births in 2019 to 6.0 in 2020. However, provisional data for 2021 indicate a return to a rate (7.0) similar to that in 2019. Still, Oklahoma has made progress in reducing infant mortality as the trajectory of the rate over a longer period of time shows a downward trend. Teen birth rates have continued to decline across all age groups between 2015 and 2020 – ages 15-17 down 37% to 10.1 births per 1,000 population, ages 18-19 down 25% to 48.1, and ages 15-19 down 28% to 25.0. These downward trends in teen childbearing were observes for all race and ethnic groups.

Preterm birth (PTB), on the other hand, is trending in the wrong direction. In 2014 and 2015, the percentage of births born prior to 37 completed weeks of gestation was 10.3% in each of those years. However, the incidence of PTB has climbed each year from 2015, reaching 11.5% in 2019, before falling to 11.1% in 2020. Relatedly, low birth weight (LBW) had reached 7.9% of all births in 2015, a year in which Oklahoma outperformed the nation (8.1%), only to rise to 8.2% in 2018, and then rising yet again to 8.3% in 2020. Maternal mortality has increased as well, rising from 18.9 maternal deaths per 100,000 live births in 2014-2016 to 29.5 in 2017-2019, and then sliding back to 25.2 in 2018-2020.

3. Changes in state’s Title V program capacity

Oklahoma’s Title V programs have experienced staffing changes. The Perinatal and Reproductive Health Division added an Advanced Practice Registered Nurse, Amy Foster, to its staff to support maternity clinics and the Maternal Health Innovation Program grant. Likewise, the Child and Adolescent Health Division hired an Advanced Practice Registered Nurse, Misty Hammons to provide technical assistance and support to Child Health clinical staff and assist with nurse and APRN trainings. As previously reported, the Assessment Division lost a staff analyst (Medicaid Analyst) to resignation in October 2020. Recruitment for the position was prolonged but a qualified candidate was hired in early July 2022 with a start data set for August 1, 2022. Rakel Cleveland (MS, Epidemiology) will join the Assessment team as the Medicaid Analyst, performing linking and analysis of Medicaid/birth records. In March 2022, a long serving PRH Epidemiologist, Dana Coles, resigned. Assessment has been successful in recruiting and hiring a replacement in short order. Jenna Bellantoni (MPH, Epidemiology) began her employment on July 6, 2022. Her responsibilities as the PRH Epidemiologist will be to support program activities in the PRH Division, including primary support for the Title X and State Maternal Health Innovation Program grants. Ms. Cleveland and Ms. Bellantoni also will provide support for the Title V Block Grant Application/Annual Report and the Five-Year Needs Assessment. Lastly, Susan Harman, who held the SSDI Analyst position in Assessment, retired at the end of 2021. Assessment has hired Cynthia Bates (MPH, Epidemiology) to serve as the new SSDI Analyst, beginning in May 2022.

The greatest challenge to Title V program capacity has been the impact of the coronavirus pandemic. While there are many duties or responsibilities that can be completed remotely via telework, there are those that cannot, which require in-person collaboration and cooperation. Having staff working remotely for extended months has slowed or delayed projects and trainings. Some work could only be placed on hold until such time that “normal” operations were resumed. Some staff were reassigned temporarily to assist with COVID mitigation efforts, for at least a few days each week. While COVID as abated in recent months, MCH continues to do much of its collaborative work virtually on TEAMS and Zoom calls.

4. Title V partnerships and collaborations

Oklahoma Title V programs have many internal and external relationships that enable or facilitate the successful achievement of goals and objectives. These partnerships and collaborations have been challenged by the coronavirus pandemic given the inability to freely meet in-person. While virtual meetings offer a substitute, they are limited and inhibit or prevent some activities. MCH and CSHCN personnel and their many partners thrive on the interaction gained by working closely together on collaborative projects. Work carried on, but full potential was likely hampered by distancing constraints and staff reassignments to assist with pandemic efforts. With the pandemic abating and the relaxation of guidelines, there will be opportunities to resume meetings with existing partners and to build new connections meaningful to building the data capacity necessary for comprehensive needs assessments of the MCH populations.

5. Operationalizing the Five-Year Needs Assessment process and findings

Oklahoma’s process for preparing the Five-Year Needs Assessment follows a standard stepped process that builds on preceding stages. Initially, MCH leadership and staff hold a series of brainstorming and planning meetings. The early stages focus on clarifying partners and key informants, outlining data collection procedures and constructing collection tools, assigning responsibilities, and formulating a tentative schedule of events. Routine meetings are scheduled to be spaced out over an 18- to 24-month period. As the submission deadline approaches, the frequency of meetings is escalated to assure that milestones are met and to troubleshoot challenges. All members of MCH staff are directly or indirectly involved in the process, with level of participation determined by the roles and responsibilities of staff. Broad oversight of the needs assessment process is provided by MCH leadership (MCH Director and Division Administrative Program Managers), as well as the Director of the CSHCN Program and the Executive Director of the Oklahoma Family Network. Day-to-day coordination of needs assessment activities is carried out by the SSDI Analyst.

6. Changes in organizational structure and leadership

Lance Frye, MD, who was confirmed as the Commissioner of Health in April 2021, resigned his post in October 2021. Following Frye’s resignation, Governor Kevin Stitt appointed Keith Reed as the Interim Commissioner of Health at the Oklahoma State Department of Health (OSDH). Mr. Reed is a long serving OSDH employee and has since been confirmed as the agency’s lead. OSDH has experienced several organization changes in the last year. Health services are split across three areas led by Deputy Commissioners for Community Health Services, Quality Assurance and Regulatory Services, and Health Preparedness. Community Health Services encompasses the county health departments, Family Health Services, Personal Health Services, Nursing Services, and Records and Community Health Systems. Quality Assurance and Regulatory Services is comprised of Long Term Care, Medical Facilities, Health Resources Development Service, and Consumer Health Services. Health Preparedness includes the Public Health Laboratory (now located in Stillwater, Oklahoma), Emergency Preparedness and Response Service, Acute Disease, Sexual Health and Harm Reduction Services, Center for Health Statistics, and Vital Records. Also, Health Preparedness is home to the Office of the State Epidemiologist and the Chief Science Officer.

Ongoing Needs Assessment Activities

Assessment staff continued routine analyses of data related to the health and health care of women, infants, and children in the state of Oklahoma. While these efforts are not regularly acknowledged as ongoing needs assessment initiatives, study findings are integrated into the understanding of the populations represented and served, and assist as a baseline for initiating the Five-Year Needs Assessment process. These efforts are constructed around established MCH priorities, grant requirements, project analysis plans, and emerging issues important to MCH target populations.

Surveillance Activities

Collection, management, analysis, and reporting of state-level data are built around MCH surveillance activities for the Pregnancy Risk Assessment Monitoring System (PRAMS), the Oklahoma Toddler Survey (TOTS), and the Youth Risk Behavior Survey (YRBS). These are surveillance projects which are mainstays for Oklahoma MCH.

Pregnancy Risk Assessment Monitoring System (PRAMS)

The state’s PRAMS project has been active for over 30 years, consistently producing high-value data for monitoring population health indicators for women and infants. The latest year of PRAMS weighted data is 2021, with an overall response rate of 53%. This is an improvement from the 40% response rate in 2020. The increase is seemingly driven primarily by implementing Amazon gift cards as a reward for survey participation. In 2021, respondents received a $10 gift card for completing the survey. The PRAMS project applied for and received funding ($25,000) from the Council for State and Territorial Epidemiologists (CSTE) to implement a COVID-19 Vaccine Supplement for a portion of the year. With this funding, PRAMS increased the gift card value to $20. In 2022, respondents received a $20 gift card for survey completion. The PRAMS project again applied for and received funding ($30,000) from CSTE to implement a Social Determinants of Health Supplement for most of the year. With this funding, PRAMS increased the gift card value to $30. Data for the 2022 collection cycle should become available in late 2023.

PRAMS published two reports and an infographic in 2022: 

• Pre-Pregnancy Binge Drinking and Maternal Mental Health: 2016-2019 Update 
• Profile of Oklahoma Mothers who Used Prescription Opioids During Pregnancy: 2016-2019 
• Electronic Cigarette Use Before Pregnancy: 2016-2019 (Infographic) 

The Oklahoma Toddler Survey (TOTS)

TOTS is Oklahoma’s PRAMS follow-back survey, sent to PRAMS respondents when their child turns two-years-old. TOTS has been active since 1994 and provides information about the health, experiences, and well-being of Oklahoma’s toddler population. The data help guide Oklahoma programs and health policy, and help better use limited resources. TOTS respondents are also sent reward items for participation. The latest year of TOTS weighted data is 2021 (corresponding to the 2019 PRAMS data collection year) with a weighted response rate of 66.5% among eligible mothers and an overall response rate of 32.3% with PRAMS. The TOTS overall response rate is a product of the PRAMS response and the response achieved during the TOTS survey administration. As a result, TOTS response rates have lagged, yielding rates inadequate for data weighting and compromising the ability to report single-year estimates. Waiting for data availability to develop multi-year estimates and data products created a delay in producing TOTS publications. Reports previously developed are available on the MCH website.

Youth Risk Behavior Survey (YRBS)

The administration of the 2023 YRBS was completed in the Spring semester of 2023. Due to sufficient school and student participation rates, Oklahoma will again receive weighted data, which will be representative of all public high school students in the state. Participating schools had two options to administer the survey; MCH-Led and School-Led. Weighted YRBS 2023 data should become available to OSDH by early 2024. Due to COVID-19, survey administration of the 2021 cycle was postponed from spring 2021 to fall 2021. OSDH received the weighted 2021 YRBS data in late fall of 2022 and the data was officially released to the public in November of 2022. This cycle included for the first time; 13 questions related to adverse childhood experiences (ACES) and three questions related to positive childhood experiences (PCS). The YRBS publications using the latest survey data available (2021) were published during the fall of 2022 and spring of 2023. Below is a list of published reports, all of which are available on the OSDH website.

• Teen Dating Violence Infographic: Oklahoma YRBS 2021
• Nutrition Infographic: Oklahoma YRBS 2021
• Alcohol Use Infographic: Oklahoma YRBS 2021
• Bullying Infographic: Oklahoma YRBS 2021
• Mental Health Infographic: Oklahoma YRBS 2021
• Adverse Childhood Experiences (ACEs) and Positive Childhood Experiences (PCEs): Oklahoma YRBS 2021
• YRBS 10-Year Trend Monitoring Report: 2011-2021

Three more infographics are currently in development with the graphic designer of our Communications Service. The three infographics are a combination of YRBS 2021 student behavior data and School Health Profiles 2020 Principal Survey. Topics covered are bullying, nutrition, and physical activity and education.

State Systems Development Initiative (SSDI)

The Oklahoma SSDI Project supports MCH service area priorities and includes objectives related to supporting the completion of the MCH Title V Five-Year Needs Assessment. Day-to-day coordination of needs assessment activities is carried out by the SSDI Analyst. Other assessment and data capacity carried out under the auspices of the State System Development Initiative (SSDI) can be found in section (iii) MCH Data Capacity (b) State Systems Development Initiative (SSDI).

Changes in Health Status and Needs of MCH population

Oklahoma MCH made no changes to the list of program priorities, remaining focused on the 10 priority needs established with FY2021 grant application. During this reporting period however, revisions to evidence-based strategy measures were made to strengthen methods of assessing the impact of Oklahoma Title V activities. The state continues to implement and maintain programs that address priorities across the lifespan.

With the use of a Provisional Data Dashboard, measures such as preterm birth, low birth weight, teen birth rate and infant mortality rate are being tracked on a monthly basis to identify any potential issues. This dashboard is currently used by the MCH Assessment Administrative Programs Manager and the Director of Maternal and Child Health Service. As maternal mortality is viewed as an indicator of the overall effectiveness of the obstetrical and the general health care systems, the maternal mortality rate is also reviewed annually.

Preterm Birth

In 2015, the percentage of births born prior to 37 completed weeks of gestation was 10.3%. The incidence of preterm birth (PTB) has climbed each year, reaching 11.9% in 2021.

Low Birth Weight

Low birth weight (LBW) had reached 7.9% of all births in 2015, a year in which Oklahoma outperformed the nation (8.1%), only to rise to 8.2% in 2018, and then rising yet again to 8.6% in 2021.

Teen Birth Rate

Teen birth rates have continued to decline across all age groups between 2015 and 2021 – ages 15-17 down 45% to 8.8 births per 1,000 population, ages 18-19 down 25% to 48.2, and ages 15-19 down 31% to 24.1. These downward trends in teen childbearing were observed for all race and ethnic groups.

Infant Mortality

The three- year rate of infant mortality was 6.7 infant deaths per 1,000 live births for 2019-2021. Provisional data for 2022 indicate a rate of 6.9, similar to that in 2021 and 2019. Still, Oklahoma has made progress in reducing infant mortality as the trajectory of the rate over a longer period of time shows a downward trend.

Maternal Mortality

Maternal mortality has increased over time, rising from 20.1 maternal deaths per 100,000 live births in 2014-2016 to 29.5 in 2017-2019, and then decreasing to 25.2 in 2018-2020. For consistency with the national maternal mortality estimates from the National Center for Health Statistics, Oklahoma computes maternal mortality estimates from vital statistics using a similar methodology.

Operationalizing the Five-Year Needs Assessment Process and Findings

Oklahoma’s process for preparing the Five-Year Needs Assessment follows a standard stepped process that builds on preceding stages. Initially, MCH leadership and staff hold a series of brainstorming and planning meetings. The early stages focus on clarifying partners and key informants, outlining data collection procedures and constructing collection tools, assigning responsibilities, and formulating a tentative schedule of events. Routine meetings are scheduled to be spaced out over an 18- to 24-month period. As the submission deadline approaches, the frequency of meetings is escalated to assure that milestones are met and to troubleshoot challenges. All members of MCH staff are directly or indirectly involved in the process, with level of participation determined by the roles and responsibilities of staff. Broad oversight of the needs assessment process is provided by MCH leadership (MCH Director and Division Administrative Program Managers), as well as the Director of the CSHCN Program and the Executive Director of the Oklahoma Family Network.

Oklahoma’s preparation for the 2026-2030 Title V Needs Assessment will begin in mid-2023 with planning meetings, development of a timeline, and identification of activities to be accomplished between then and the submission in July 2025. Initial efforts currently underway include:

• reviewing materials implemented during the previous needs assessment including public input surveys, key informant surveys, and focus group scripts
• identifying community health assessments previously developed by community agencies, county health departments, and hospital systems and review for identified priorities pertaining to the MCH population
• establishing communications with the OSDH Tribal Liaison to schedule tribal listening sessions

Title V Partnerships and Collaborations

Oklahoma Title V programs have many internal and external relationships that enable or facilitate the successful achievement of goals and objectives. These partnerships and collaborations have been resumed since the coronavirus pandemic, given the ability to meet in-person. Virtual meetings are still available and allow for more individuals to attend and participate. MCH and CSHCN personnel and their many partners thrive on the interaction gained by working closely together on collaborative projects. With the pandemic abating and the relaxation of guidelines, there are opportunities to resume meetings with existing partners and to build new connections meaningful to building the data capacity necessary for comprehensive needs assessments of the MCH populations.

Changes in Title V Program Capacity, Organizational Structure, and Leadership

The greatest challenge to Title V program capacity in the past couple of years has been the impact of the coronavirus pandemic. As the Oklahoma State Department of Health (OSDH) began its transition toward the endemic phase of this pandemic, there has been an increase of in-person collaboration and work that was placed on hold has been resumed.

Within OSDH MCH, the Administrative Programs Manager (APM) for MCH Assessment, and Title V Data Contact for many years, resigned in August 2022. The interim APM, Binitha Kunnel, was promoted to APM in 2023. With this change, there is now a vacant Senior Biostatistician/Epidemiologist III position, whose role is described in section (iii) MCH Data Capacity (a) MCH Epidemiology Workforce. The MCH Nutritionist retired in October 2022, and the position is vacant as of May 2023. Although much of the breastfeeding work continues, there are gaps in knowledge and projects that are on hold until a permanent replacement is found.

(a)  Ongoing Needs Assessment Activities

Surveillance Activities

Assessment staff continued routine analyses of data related to the health and health care of women, infants, and children in the state of Oklahoma. Study findings are integrated into the understanding of the populations represented and served and assist as a baseline for initiating the Five-Year Needs Assessment process. These efforts are constructed around established MCH priorities, grant requirements, project analysis plans, and emerging issues important to MCH target populations.

With the launch of a public facing MCH Data Portal (Data Portal) in July 2023, the process of reviewing data updates and changes in the MCH population has become more streamlined and accessible to various Title V partners with the click of a button. The Data Portal provides quick access to maternal, infant, and children’s health information in the form of reports and interactive dashboards that are updated as new data becomes available. Details on the development of the MCH Data Portal are explained in Section (iii) MCH Data Capacity (b) State Systems Development Initiative (SSDI). The Oklahoma MCH Data Portal can be found online at this link: https://oklahoma.gov/health/mchdataportal.html.

An internal Provisional Data Tracker dashboard is updated monthly by the SSDI Analyst to track measures such as preterm birth, low birth weight, teen birth rate, infant mortality rate, SUIDs, and SIDS to identify any data inaccuracy or emerging issues. This dashboard is reviewed by the MCH Assessment Administrative Programs Manager and the Director of MCH.

As maternal mortality is viewed as an indicator of the overall effectiveness of the obstetrical and the general health care systems, maternal mortality rate is also reviewed annually with a report released and made available to the public. The latest report can be found at: MMRCAnnualReport2023PRINT1.pdf (oklahoma.gov)

Collection, management, analysis, and reporting of state-level data are built around MCH surveillance activities for the Pregnancy Risk Assessment Monitoring System (PRAMS), the Oklahoma Toddler Survey (TOTS), and the Youth Risk Behavior Survey (YRBS). These are surveillance projects which are mainstays for Oklahoma MCH.

Pregnancy Risk Assessment Monitoring System (PRAMS)

The state's PRAMS project has been active for over 35 years, consistently producing high-value data for monitoring population health indicators for women and infants. The latest year of PRAMS weighted data is 2021, with an overall response rate of 53%, an improvement from the 40% response rate in 2020. The increase seems driven primarily by implementing Amazon gift cards as a reward for survey participation. For 2022 births, the Oklahoma PRAMS project applied for and received funding ($30,000) from the Council for State and Territorial Epidemiologists (CSTE) to implement a Social Determinants of Health Supplement for most of the year. With this funding, PRAMS offered respondents a $30 gift card. Much time and effort was directed at the end of 2022 through mid-year of 2023 in revising the PRAMS surveillance instrument (Phase 9) and all accompanying documents and protocols. PRAMS began using the Phase 9 instrument with 2023 births, which included updated emerging and priority issues related to the maternal and infant population. Phase 9 also provided an option for online survey completion. Online respondents received a $20 gift card for participation. Data for the 2022 collection cycle should become available in spring 2024.

PRAMS produced the following publications during the reporting period, which are available through the Data Portal:

• Breastfeeding among Mothers with Pre-term and Term Births (PRAMS Brief)
• Association of Pre-Pregnancy Health Conditions and Select Birth Outcomes among Oklahoma Mothers (Report)

The Oklahoma Toddler Survey (TOTS)

TOTS is Oklahoma's PRAMS follow-back survey, sent to PRAMS respondents when their child turns two years of age. TOTS has been active since 1994 and provides information about the Oklahoma toddler population's health, experiences, and well-being. The data help guide Oklahoma's programs and health policies and help better use limited resources. TOTS respondents are sent reward items for participation. The latest year of TOTS weighted data is 2022 (corresponding to the 2020 PRAMS data collection year), with a weighted response rate of 57% among eligible mothers and an overall response rate of 23% with PRAMS. The TOTS overall response rate is a product of the PRAMS response and the response achieved during the TOTS survey administration. The PRAMS response rate for 2020 was low (40%). As a result of this and previous years' lower responses, TOTS response rates have lagged, yielding rates inadequate for data weighting and compromising the ability to report single-year estimates. Therefore, TOTS uses multi-year aggregated data to produce publications. During the reporting period, this created a delay in producing TOTS publications. Reports previously developed are available through the Data Portal.

Youth Risk Behavior Survey (YRBS)

The administration of the 2023 YRBS was completed January through May 2023. Participating schools had two options to administer the survey; MCH-Led and School-Led. Of the 50 randomly selected schools, 38 schools participated for a school response rate of 76%. Of the 2,119 sampled students, 1,748 students participated for a student response rate of 82%. The overall response rate, which is the school response rate times the student response rate, was 63%. Non-response bias analysis was conducted and the data were weighted to be representative of all public high school students in Oklahoma. The weighed 2023 data were submitted to OSDH in February 2024, from which fact sheets, infographics, and reports will be developed and shared with internal and external partners and posted to the Data Portal. The Youth Risk Behavior Surveillance System (YRBSS) monitors six categories of priority health-risk behaviors among youth and young adults including behaviors that contribute to unintentional injuries and violence; tobacco use; alcohol and other drug use; sexual behaviors that contribute to unintended pregnancy and sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) infection; unhealthy dietary behaviors; and physical inactivity.

State Systems Development Initiative (SSDI)

The Oklahoma SSDI Project supports MCH service area priorities and includes objectives related to supporting the completion of the MCH Title V Five-Year Needs Assessment. Day-to-day coordination of needs assessment activities is carried out by the SSDI Analyst. Other assessment and data capacity tasks carried out under the auspices of the SSDI can be found in Section (iii) MCH Data Capacity (b) State Systems Development Initiative (SSDI).

(b) Operationalizing the Five-Year Needs Assessment Process and Findings

Oklahoma’s preparation for the 2026-2030 Title V Needs Assessment began in May 2023 with planning meetings, timeline development, and identification of activities to be completed between May 2023 and submission in July 2025.

Needs Assessment efforts completed during this reporting period included the following:

1. Strategic Plan Development: In May 2023, a strategic plan was developed and presented to the Title V Block Grant Coordinator outlining the schedule for the two-year process to direct staff in the evaluation and selection of Title V priorities and performance measures.

This plan for the Oklahoma Title V Needs Assessment has five main phases:

• Planning and Design
• Data Collection and Capacity
• Needs Analysis
• Plan Development
• Needs Assessment Summary

Phase 1 of the plan took place during this reporting period.

Figure 1: Oklahoma Title V Needs Assessment Five Phases

3. Organizational Structure Development: An organizational structure was developed to ensure communication and vested interest. The co-leads in this structure include the Title V MCH Director, the Title V Block Grants Coordinator, the Title V CSHCN Director, and the Assessment APM (core team). The core team will inform and make the final decisions on the process and priorities and includes representatives from OSDH, DHS, and OFN. The data team will report to the core team and will organize and implement the process and includes Title V data analysts and epidemiologists.

4. Title V Training: To prepare for the Title V Needs Assessment, separate trainings were held for MCH and CSHCN staff (including their contract providers) before implementing the plan. This training served as a refresher for staff who participated in previous Title V Needs Assessments, as well as training for newer staff.

5. Partner Identification: At the end of August 2023, a partner mapping activity took place with all MCH staff. The Title V Needs Assessment team (Needs Assessment) used this activity to identify and generate information about partners to understand their interests and assess their influence to successfully implement the needs assessment. The same process took place among DHS CSHCN and their contract providers.

6. Needs Assessment Data Book Development: To inform Needs Assessment, the Data Team created a Data Book. This comprehensive resource references relevant data sources and MCH need indicators, serving as a central repository for all data gathered during the assessment process.

7. Priority Setting Process Selection: With the priority setting process, the goal was to develop an inclusive and state specific process prior to when data collection began to reduce any potential bias. There will be multiple rounds of priority setting, the first of which will include individual ranking where individuals will rank their top three choices in each MCH Domain. The next round will include a criteria-based approach with eight separate criteria.

8. Listening Session Planning: Eight listening sessions will be completed between March 2024 and September 2024. These sessions will prioritize engagement with specific communities, including five for Tribal Nations, one for the Black/African American community, one for the Hispanic/Latino community, and one focused on youth voice. The listening sessions were coordinated in partnership with OFN and OKDHS. In April 2023, the SSDI Analyst and Assessment APM conducted an introductory meeting with the OSDH Tribal Liaison to coordinate the Tribal Listening Sessions. Recognizing the valuable insights Tribal Listening Sessions offer in understanding MCH strengths and needs, an introductory meeting was held early in the needs assessment process. This proactive step allowed for thorough planning and ensured these sessions maximize the collection of qualitative data.

(c) Changes in Health Status and Needs of MCH Population

MCH has made no changes to the list of program priorities, remaining focused on the 10 priority needs established with the FY2021 grant application. MCH continues to implement and maintain programs that address priorities across the lifespan.

Pregnancy Risk Factors

According to Behavioral Risk Factor Surveillance Survey (BRFSS) data, there is an observed decrease in females aged 18-44 who are currently smoking with a decrease of 33% from 2015 to 2022. There is no observed increase or decrease in females aged 18-44 who were diagnosed with diabetes or high blood pressure.

Maternal Mortality

From 2019 to 2021, Oklahoma had an Maternal Mortality Rate (MMR) of 31.0 maternal deaths per 100,000 live births The MMR increased substantially from 25.2 in the 2018-2020 time period to 31.0 in the 2019-2021 time period, a 23% increase. This increase follows a similar trend to the national MMR, likely in part due to the effects of the COVID-19 pandemic. From 2019-2021, deaths related to COVID-19 comprised 20% of maternal deaths in Oklahoma.

Preterm Birth and Low Birth Weight

In 2021, the percentage of births born prior to 37 completed weeks of gestation was 11.9%. This rate has been increasing slowly since 2015, which had a preterm birth (PTB) incidence of 10.3%. In 2022, there was a decrease in PTB incidence to 11.3%. The incidence of PTB remains highest among the Non-Hispanic (NH) Black infants with 16.3% of infants being born premature in 2022 compared to 10.7% White infants.

Low birth weight (LBW) had reached the highest rate in 10 years with 8.8% in 2021. in 2021 with 7.9% of all births in 2015, a year in which Oklahoma outperformed the nation (8.1%), only to rise to 8.8% in 2021. In 2022, LBW has dropped slightly to 8.5%.

Infant Mortality

The Infant Mortality Rate (IMR) for 2022 was 6.9, similar to that in 2021 and 2019. Oklahoma has made progress in reducing overall infant mortality as the trajectory of the rate over a longer period of time shows a downward trend.

Teen Birth Rate

Teen birth rates have continued to decline across all age groups between 2015 and 2021 – ages 15-17 down 45% to 8.7 births per 1,000 population, ages 18-19 down 37% to 40.7, and ages 15-19 down 39% to 21.2. These downward trends in teen childbearing were observed for all race and ethnic groups.

Youth Mental Health

Based on a trend of YRBS data, there was a 12.7% increase from 2019 to 2021 in the percentage of students who ever felt sad or hopeless almost every day for two weeks or more in a row that they stopped doing some usual activities.

(d) Title V Partnerships and Collaborations

For details on the robust Title V partnerships and collaborations in Oklahoma please see section III.E.2b.v.a.

(e) Changes in State’s Title V Program Capacity, Organizational Structure, and Leadership

Within MCH, there have been several staff changes during this program period. The PRAMS/TOTS Analyst position was filled in August 2023. Also, in August 2023, the Medicaid Data Analyst position was vacated, however the position was filled in March 2024.

The Health Equity and Special Projects Coordinator left at the end of December 2023. In January 2024 the Social Work and Safe Sleep Coordinator resigned and in March 2024 the Adolescent Health Coordinator took another position within OSDH. Due to a hiring freeze for state agencies it is unlikely that MCH will be able to refill these positions in the next year.