Maternal and Child Health MCH Childrens Special Health Services CSHS Planning Retreat

1
Maternal and Child Health (MCH)Childrens
Special Health Services (CSHS)Planning Retreat

• October 28, 2004
• Pioneer Room
• ND State Capitol
• Bismarck, ND

2
Why Are We Here?

• The State must prepare a statewide needs
  assessment every 5 years that shall identify
  (consistent with health status goals and national
  health objectives) the need for
• Preventive and primary care services for pregnant
  women, mothers and infants
• Preventive and primary care services for
  children, and
• Services for CSHCN
• Title V of the Social Security Act
• Section 505 (a)(1)

3
How Will We Do This?

• Review and study the data that tells us about the
  health of the maternal and child health
  population in North Dakota.
• Use this information to help identify which are
  the most important priority health needs.
• Discuss ways in which we can work together to
  improve the health of the MCH population.

4
Maternal and Child Health PopulationTop 5 Health
Issues From Participant Survey

• Inadequate insurance coverage (25)
• Lack of knowledge about resources programs (22)
• Access to dental care (21)
• Lack of health insurance (17)
• Poverty/income (17)
• Access to mental health services (17)

5
Population Changes Females
The population of women age 20-44 decreased by
nearly 8,000 between 1990 and 2000 in ND. The
population of White women decreased by nearly
10,000 while the population of women who are
American Indian or of other races increased
Maternal and Child Health Population
6
Population Changes Children
The population of children age 0 to 19 in ND
decreased by more than 12,500 between 1990 and
2000. The number of White children declined by
more than 17,000 while the population of minority
children increased by nearly 5,000
Maternal and Child Health Population
7
Health Insurance Coverage

• A 2004 survey conducted by UNDs Center for Rural
  Health found 8.2 of North Dakotans were
  uninsured.
• More than 11,000 children under age 18 were
  uninsured.
• An additional 4 of children were underinsured
  defined as annual out-of-pocket expenses gt10 of
  median annual household income.

Maternal and Child Health Population
8
Poverty by Family Type
38.7 of ND families headed by a single mother
are in poverty compared to 20.1 of single father
families and only five percent of married couple
families.
Maternal and Child Health Population
9
Median Family Income
Median family income is substantially higher
among married couple as families with children
compared to families headed by single fathers or
single mothers.
Maternal and Child Health Population
10
Working Women Mothers
The percent of females age 16 or older working
and the percentage of households with children
under age 6 with both parents working increased
in North Dakota between 1990 and 2000.
Maternal and Child Health Population
11
Women, Mothers and Infants

• Population group description
• Adolescent females and adult women age 14-44
• Pregnant women and mothers
• Infants birth up to age 1

12
Top 5 Health Issues From Participant Survey

• Prenatal care (27)
• Prenatal tobacco use (24)
• Alcohol use (22)
• Breastfeeding (21)
• Domestic violence/abuse (17)

Women, Mothers and Infants
13
Adequacy of Prenatal Care
Between 1998 and 2002 88 of ND mothers received
adequate prenatal care. However, a lower
percentage of American Indian mothers and mothers
on Medicaid had adequate prenatal care.
The Kotelchuck prenatal care index measures
adequacy of care based on a formula that includes
month of initiation and number of visits.
Women, Mothers and Infants
14
Tobacco Use During Pregnancy
The percent of ND mothers using tobacco during
pregnancy decreased from 19.4 in 1998 to 17.2
in 2002. During this time the state rate was
higher than the national rate and percent among
ND American Indian mothers is more than twice the
rate for White mothers.
Women, Mothers and Infants
15
Tobacco Use During Pregnancy
Medicaid mothers were three times as likely to
smoke up to the last three months of their
pregnancy than non-Medicaid mothers, but were
also more likely to quit before their third
trimester.
Women, Mothers and Infants
16
Current Cigarette Smokers
The percent of ND women age 18-44 who are current
smokers has decreased from 27.4 in 1999 to 25.6
in 2003 but is still substantially higher than
the HP 2010 goal of 12.
A current smoker is someone who has smoked at
least 100 cigarettes in their lifetime and now
smokes some days or every day.
Women, Mothers and Infants
17
Alcohol Use and Pregnancy
Women on Medicaid were less likely to report not
using alcohol during the three months before
their pregnancy than non- Medicaid women, but the
vast majority of both Medicaid and non-Medicaid
pregnant women report not using alcohol during
their last trimester of pregnancy.
Abstaining from alcohol is defined as reporting
they had no drinks or didnt drink then
Women, Mothers and Infants
18
Breastfeeding
More than 3 in 5 ND mothers breastfeed their
infant at hospital discharge but the percentage
drops to 1 in 5 by six months (among the WIC
population). American Indian mothers breastfeed
at a much lower rate than White mothers.

• The overall state rate of breastfeeding at
  hospital discharged has been between 60 and 62
  percent over the last 5 years.
• The HP 2010 goal for early postpartum
  breastfeeding is 75 and 50 at 6 months

Women, Mothers and Infants
19
Domestic Violence
Women on Medicaid were about 4 times more likely
to experience abuse both before and during their
pregnancy than women not on Medicaid.
Women, Mothers and Infants
20
Domestic Violence
Between 2001 and 2003, there were about 4,000 new
victims of domestic violence each year in North
Dakota.
About 94 of victims of domestic violence are
women and about 3 are children under age 18.
Women, Mothers and Infants
21
Domestic Violence

• Between 2001 and 2003.
• Three percent of new victims were pregnant at the
  time of the abuse.
• 13 of new victims were disabled nearly half of
  them with a mental illness.
• 18 of new victims were American Indian.
• 42 of new victims were under the age of 30.
• Source ND Council on Abused Womens Services

Women, Mothers and Infants
22
Infant Mortality
During the five-year period 1998-2002, the infant
mortality rate in North Dakota was slightly
higher than the rate in the United States overall
but substantially higher than the HP 2010 goal of
4.5.
Women, Mothers and Infants
23
Infant Mortality by Cause of Death
Congenital anomalies were the leading known cause
of infant death among North Dakota babies between
1997-2001 followed by SIDS and Short
Gestation/Prematurity
Women, Mothers and Infants
24
Infant Mortality by Race
Between 1998 and 2002, the Infant Mortality rate
among North Dakota American Indian infants
increased from 5.1 to 14.0, more than twice the
rate of White infants.
Rates per 1,000 births referenced in this chart
are three-year running averages. 1998 data is
for the years 1996-1998, 1999 data is for the
years 1997-1999.
Women, Mothers and Infants
25
Causes of Infant Mortality by Race
The rate (per 10,000 births) of infant mortality
due to congenital anomalies was higher in White
infants but the rate due to SIDS was nearly three
times higher for American Indian infants than
White
Women, Mothers and Infants
26
Infant Sleep Position
Sleep position is a known risk factor for Sudden
Infant Death Syndrome (SIDS). The percent of ND
babies placed an their backs to sleep increased
from 57 in 1996 to 77 in 2002.
Women, Mothers and Infants
27
Infant Birth Weight
Each year in ND, about 6 of babies are born low
birth weight (lt 5lbs 8oz) and about 1 very low
birth weight (lt 3lbs 4oz). The percent of ND
births LBW was lower than the national percent
between 1998 and 2002.
The HP 2010 target for low birth weight is 5.0
and 0.9 for very low birth weight
Women, Mothers and Infants
28
Healthy Weight Status
The percent of ND women age 18-44 overweight (BMI
25.0-29.9) increased between 2000 and 2003. The
percent obese (BMI 30.0 and above) more than
doubled from 7.4 to 18.3.
Women, Mothers and Infants
29
Pre-Pregnancy Healthy Weight
Women on Medicaid were more likely to have a
pre-pregnancy weight status falling in the
underweight or overweight or obese range than
women who were not on Medicaid.
Underweight BMI lt19.8 Normal BMI 19.8
26.0 Overweight or Obese BMI gt 26.0
Women, Mothers and Infants
30
Physical Activity
In 2003, 42 of women age 18-44 had the
recommended amount of moderate physical activity
and one in three the recommended amount of
vigorous physical activity.
Vigorous physical activities are activities that
result in large increases in breathing and heart
rate while moderate physical activity results in
some increase in breathing and heart rate. The
recommendation is for 10 or more minutes at a
time 3 or more days per week.
Women, Mothers and Infants
31
Intendedness of Pregnancy
Nearly two-thirds of mothers indicated their
pregnancy was planned saying they wanted to be
pregnant at the time they got pregnant or sooner.
Women on Medicaid during their pregnancy were
less likely to have a planned pregnancy than
women who were not on Medicaid.
Women, Mothers and Infants
32
Maternal Medical Risk Factors
Each year in North Dakota about three percent of
women have pregnancy-associated hypertension and
four percent gestational diabetes. Between 1999
and 2003, ND American Indian women were more
likely to have pregnancy- associated hypertension
but White women more likely to have gestational
diabetes.
Women, Mothers and Infants
33
Folic Acid Consumption
Between 2000 and 2003, the percent of North
Dakota women of childbearing age taking a
multivitamin or folic acid containing supplement
has increased but is still well below the Healthy
People 2010 goal of 80.
Women, Mothers and Infants
34
Children and Adolescents

• Population group definition
• Children age 1 up to age 18.

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Retreat Participant Survey Results

• Top 5 Health Issues Affecting Children and
  Adolescents in North Dakota
• 1. Adolescent drug alcohol use (28)
• 2. Healthy weight (27)
• 3. Access to health care (24)
• 4. Adolescent tobacco use (16)
• 5. Youth violence/bullying (15)

36
Adolescent Alcohol Use
According to the 2003 Youth Risk Behavior Survey,
North Dakota high school students were more
likely to be current users of alcohol and to
binge drink than high school students nationally
High school students represent those in grades 9
through 12
Children and Adolescents
37
Adolescent Alcohol Use
In 2003, North Dakota high school students rode
with a driver who had been drinking and drove
after drinking much more often than high school
students nationally.
Children and Adolescents
38
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39
Adolescent Drug Use
The percent of ND high school students who
currently use marijuana and who first tried
marijuana before the age of 13 increased between
1995 and 2003.
Children and Adolescents
40
Mental Health and Addiction Disorders

• It is estimated that nearly 34,000, or about 1 in
  5,
• ND children have a diagnosable mental health or
  addiction disorder.
• About 6,500 ND children have a serious emotional
  disturbance
• More than 3,000 ND children are in need of mental
  health or addiction services at any given time.

Source ND Department of Human Services
41
Overweight Among 2-5 Year Olds
The percent of children between the ages of 2 and
5 in the ND WIC program who are overweight
increased between 1993 and 2003. The rate among
American Indian children is nearly twice that for
Caucasian children.
42
Inactivity Among 6th Graders
Nearly a third of ND 6th graders are physically
inactive 1-2 hours each day and 15 are inactive
more than 2 hours each day.

• Physically inactive is defined as engaged in
  activities such as
• Watching TV/videos/movies
• Reading
• Homework
• Nintendo/computer games
• Talking on the telephone
• Hanging out with friends

Children and Adolescents
43
Overweight Among 6th Graders
One in six (16) of ND 6th graders are
overweight. More boys are overweight than girls
and 6th graders living in rural areas are more
likely to be overweight than those living in
urban areas.
Overweight is defined as a Body Mass Index (BMI)
greater than or equal to the 95th percentile for
their age.
Children and Adolescents
44
Adolescent Weight and Body Image
More male ND high school students were
overweight, or at risk of becoming overweight
than females but more girls than boys (4 in 10)
thought they were overweight.
Children and Adolescents
45
Access Health Insurance Coverage
The estimated percent of ND children uninsured
has decreased from 12.1 percent in 2000 to 7.5
percent in 2003, lower than the percent
nationally.
Children and Adolescents
46
Access Health Insurance Coverage

• More than 11,000 children under age 18 are
  uninsured in North Dakota.
• 28 of the uninsured children are American
  Indian.
• More than 4,000 of the uninsured children live in
  families with incomes at 100 or less than the
  Federal Poverty Level (FPL).
• Another 3,000 of the uninsured children live in
  families with incomes between 126 and 185 of
  the FPL.
• 85 of the uninsured children have at least one
  parent who works outside the home.

Source UND Center for Rural Health
Children and Adolescents
47
Access Health Insurance Coverage

• Of ND children NOT considered to have a special
  health care need
• 10.5 did not have insurance at sometime during
  the last year.
• Of those, more than a third were uninsured all 12
  months.
• Costs too much was the main reason given for
  having no health insurance.
• National CSHCN Survey, 2002

Children and Adolescents
48
Tobacco Use
Although higher than teens nationally, according
to the Youth Risk Behavior Survey, the percentage
of ND high school students reporting current
cigarette and smokeless tobacco use has decreased
each year since 1999.
Children and Adolescents
49
Sexually Transmitted Diseases
The number of reported cases of Chlamydia in ND
teens age 15-19 nearly doubled between 1997 and
2003.
Children and Adolescents
50
Childhood Immunization
Each year between 1999 and 2003 about 4 in 5
North Dakota children age 19 to 35 months were
fully immunized (completion of the 43133
series of vaccinations) a higher percentage
than the United States overall
Children and Adolescents
51
Oral Health
Between 1999 and 2003, more than eighty percent
of ND middle school students saw a dentist at
some time during the year, higher than the
percent for high school students.
Middle School 7th 8th grade High School 9th
thru 12th grade
Children and Adolescents
52
Oral Health
Between 1999 and 2003, nearly sixty percent of ND
high school students reported having one or more
cavities in their permanent teeth.
High school students in grade 9 through 12
Children and Adolescents
53
Adolescent Violence
More than one in four ND high school students
report being in fight during the last year and
nearly 9 in a fight on school property. One in
ten report that their boyfriend or girlfriend hit
slapped, or hurt them in the last year.
High school students 9th through 12th graders
Children and Adolescents
54
Juvenile Crime
In 2000 and 2001, more than 8,000 ND children
were arrested and 6,000 were referred to juvenile
court.
Children and Adolescents
55
Child Abuse and Neglect
Each year in North Dakota, there are more than
4,000 reports of child abuse and neglect
involving more than 7,000 suspected child victims.
Children and Adolescents
56
Children Affected by Domestic Violence
The number of ND children affected by domestic
violence has increased to nearly 5,000, more than
3 of all children in the state.
Children and Adolescents
57
Child and Adolescent Mortality
Between 1999 and 2001, unintentional injuries
accounted for more than half of all deaths to ND
children age 1-19. Suicide was the second
leading cause of death followed by malignant
neoplasms.
Children and Adolescents
58
Child and Adolescent Mortality
During the 3-year period between 1999 and 2001,
nearly 7 in 10 of the child and adolescent deaths
due to unintentional injuries was the result of
motor vehicle accidents. The overall
unintentional injury mortality rate, and the rate
due to motor vehicle accidents was nearly three
times higher among American Indian children than
White children.
Children and Adolescents
59
Adolescent Suicide
Although the North Dakota suicide mortality rate
in teens age 15-19 is higher than the national
rate, the state rate has shown a declining trend
since 1994.
Children and Adolescents
60
Teen Birth Rate
The rate of births to ND teens age 15-17 has
decreased each year since 1998.
3-year averages were calculated as follows 1998
data represents the years 1996-1998, 1999 data
represents the years 1997-1999..
Children and Adolescents
61
Teen Birth Rate by Race
The North Dakota birth rate to teens age 15-17 is
significantly lower then the national rate.
However, the rate among ND American Indian teens
is substantially higher than the rate for White
teens.
Children and Adolescents
62
Access School Nursing
In 2002, there were nearly 5,000 students for
every school nurse in North Dakota, substantially
higher than the ratio of 750 students for every
nurse recommended by the National Association of
School Nurses.
Children and Adolescents
63
Children with Special Health Care Needs

• Population group definition
• Children with special health care needs (CSHCN)
  are those who have or are at risk for a chronic
  physical, developmental, behavioral or emotional
  condition and who also require health and related
  services of a type or amount beyond that required
  by children generally.

Maternal and Child Health Bureau, 1997
64
Top 5 Health Issues From Participant Survey

• Availability of specialists (23)
• Impact on families (21)
• Lack of support/ancillary services (20)
• Transition to adulthood (16)
• Lack of screening programs and early intervention
  services (16)
• Family participation/involvement (16)

Children with Special Health Care Needs
65
Indicators

• Health status
• Health care access
• Screening and early detection
• Impact on families
• Health system national core measures

Children with Special Health Care Needs
66
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67
Prevalence of Chronic Disease Asthma
An estimated 12.7 of ND children have ever been
diagnosed with asthma (2002 BRFSS) compared to
12.2 of children nationally who have ever been
told they have asthma (2002 NHIS).
Children with Special Health Care Needs
68
Prevalence of Chronic Disease Diabetes
Between 1998 and 2000, it was estimated about 1
in 300 children (3.5/1,000) under age 18 in the
ND Medicaid program had diabetes. The rate was
substantially higher for American Indian children
than White children.
Children with Special Health Care Needs
69
Inpatient Hospital Admissions
Excluding admission for newborn delivery, between
2002 and 2003 there were nearly 4,000 inpatient
hospitalizations among ND Medicaid children under
age 18. The leading causes of hospitalization
were mental and behavioral disorders, followed by
respiratory diseases and other infections,
diseases and illness.
Children with Special Health Care Needs
70
Birth Defects
The rate of selected birth defects in North
Dakota during the five-year period 1997-2001 was
statistically comparable to 1999 rates from the
Metropolitan Atlanta Congenital Defects Program.
Children with Special Health Care Needs
71
Access Special Education Participation
Between the 1990-1991 and 2001-2002 school years,
the number of children eligible for special
education in North Dakota under the emotionally
disturbed category increased from 499 to more
than 1,100. The number eligible under the other
health impaired category increased from 168 to
960.
Children with Special Health Care Needs
72
Access Health Insurance Coverage Status
More than three in four children served by CSHS
and CSHCNs in the state were covered by private
insurance in 2002 fewer than five percent were
not insured.
Children with Special Health Care Needs
73
Access Usual Health Care Source
Eighty-eight percent of ND CSHCN indicated they
have a usual source of health care. Of those, an
equal number said their source was either a
doctors office or a clinic.
Children with Special Health Care Needs
74
Access Personal Doctor and Type
Eighty-nine percent of ND CSHCN indicated they
had a personal doctor. Of those, 40 of the
personal doctors were general doctors and
one-third pediatricians.
Children with Special Health Care Needs
75
Access Pediatric Specialty Care Providers
44 of North Dakota children live in one of North
Dakotas 3 Metropolitan Statistical Areas (MSAs)
Fargo, Grand Forks, and Bismarck. In 2002,
there were 79 pediatricians and 44 other
pediatric sub-specialists practicing in North
Dakota. The majority of pediatric specialty care
providers practice in one of the 3 MSAs
Children with Special Health Care Needs
76
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77
Newborn Hearing Screening
The percent of ND newborns screened for hearing
impairments at hospital discharge increased from
thirty-nine percent in 1998 to more than
ninety-five percent in 2003.
Children with Special Health Care Needs
78
Newborn Metabolic Screening

• Virtually 100 of babies born in ND are screened
  for metabolic diseases.
• Currently, ND screens for 39 separate conditions.
• All newborns who are suspected or confirmed to
  have one of the diseases are offered referral and
  follow up.

Source ND Department of Health
Children with Special Health Care Needs
79
Health Tracks Screening (under age 1)
The percent of Medicaid eligible children under
age 1 in North Dakota receiving an initial or
periodic screening increased from 54 percent in
1998 to 71 percent in 2002.
Children with Special Health Care Needs
80
Early Childhood Services
Eligibility for early intervention services is
based on identified delays in development or
informed clinical opinion. The number of young
children under age 3 served by the ND Early
Intervention program increased from 251 in 2001
to 389 in 2003.
Between July 2002 and June 2003, Right Track
staff completed 4,852 home-based developmental
screenings.
Children with Special Health Care Needs
81
Impact on Children
According to a survey of parents in ND, 4 of
CSHCNs have needs that change all the time and
one in seven (13) report their childs condition
has greatly affected their ability. 9 of CSHCNs
missed more than 10 school days last year due to
an illness or injury.
Children with Special Health Care Needs
82
Impact on Families
More than one in five families of CSHCN in ND
indicated their childs health problems have
caused financial problems for them. One in six
(15.7) needed additional income to pay for their
childs medical expenses.
Children with Special Health Care Needs
83
Impact on Families
Of the families served by CSHS, more than
two-thirds indicated they paid co-pays out of
pocket during the past year and more than half
paid costs for deductibles, medicine/prescriptions
or insurance premiums.
Children with Special Health Care Needs
84
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85
Core National Outcomes

• Medical home
• Family participation in decision-making
• Adequate insurance
• Service system organization
• Transition to adult life
• Screening

Children with Special Health Care Needs
86
Medical Home

• Components
• 88 have a usual source of sick and preventive
  care.
• 89 have a personal doctor or nurse.
• 81 have no problems getting referral when
  needed.
• 44 receive effective care coordination when
  needed.
• 71 receive family-centered care.

Children with Special Health Care Needs
87
Family Participation in Decision-Making

• Components
• 86 say doctors make the family feel like a
  partner.
• 64 of families are satisfied with services
  received.

Children with Special Health Care Needs
88
Adequate Insurance

• Components
• 95 of child have public or private insurance.
• 87 had no gaps in coverage during the year.
• 89 feel Insurance usually or always meets
  childs needs.
• 72 feel costs not covered are reasonable.
• 92 have insurance that permits child to see
  needed providers.

Children with Special Health Care Needs
89
Service System Organization

• Component
• 83 feel services are usually or always
  organized for easy use.

Children with Special Health Care Needs
90
Transition to Adult Life

• Components
• 13 of children have received guidance and
  support in the transition to adulthood.
• 55 have had doctors talk to them about changing
  needs.
• 58 of children have a plan for addressing
  changing needs.
• 34 report doctors have discussed shift to adult
  provider.
• 29 of children have received vocational or
  career training.

Children with Special Health Care Needs
91
What Families of CSHCN Say

• Families are often confused and frustrated about
  where to get information about the services
  available for their child.
• Many expressed feelings of being stressed or
  burned out with the responsibilities of caring
  for their child.
• They are generally pleased with the care provided
  by health care professionals but there is often a
  lack of coordination among the different
  providers.
• Health care professionals sometimes overlook the
  contributions parents can have in planning care
  for their child.

Children with Special Health Care Needs
Source CSHS Needs Assessment Agency MABU
92
What Families of CSHCN Say

• When seeking financial assistance for their
  child, families expressed frustration with
  paperwork requirements, that assistance continued
  to be cut, and felt being looked down upon by
  people who administer the programs. Some said
  they dont seek assistance because the process is
  too difficult or degrading.
• Some Native American families felt their unique
  cultural needs and concerns were not being
  addressed.
• Families need more respite care from qualified,
  well trained providers.

Children with Special Health Care Needs
Source CSHS Needs Assessment Agency MABU
93
What Pediatric Providers Say

• Less than one-fourth thought the availability of
  resources in their community to meet the needs of
  CSHCN was very good or excellent nearly half
  thought it was fair or poor.
• Lack of awareness about available services and
  lack of adequate insurance coverage were their
  two most common barriers to providing services to
  CSHCN.
• Lack of a coordinated funding system and
  fragmentation of services were the two most
  common systems barriers identified.
• Respite care or other family support services and
  mental health services were the two most common
  services mentioned lacking within their community.

Children with Special Health Care Needs
Source CSHS Needs Assessment Agency MABU
94
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95
Children with Special Health Care NeedsPriority
Needs

•  
•  

96
Children and AdolescentsPriority Needs

97
Women, Mothers, and InfantsPriority Needs