North Dakota Title X, Family Planning Needs Assessment.
Mariel López-Valentín works for the Office of State Epi, Division of Special Projects, and Health Analytics. On 2002 she obtained a MS in Epidemiology from the University of Puerto Rico, Medical Sciences Campus and successfully completed two fellowship programs: 2004 ASPH/CDC and (2005-2007) II Class CDC/CSTE. “I am a Data Analyst, dedicated to the expert applications of Epidemiology and Biostatistics methods, giving sense to numbers, studying public health problems in North Dakota, essential data analysis for decision making”.
Grace Njau is the director of the Division of Special Projects and Health Analytics at the North Dakota Department of Health. Grace is passionate about all-things-data, and especially rapid and targeted data dissemination to inform policy and program planning.
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. Key findings are summarized below.
Births, Fertility and Pregnancy
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). The composition of the state’s population has also changed. While still predominately white, North Dakota is becoming more diverse. In 2000, 92 percent of North Dakota’s population was White, non-Hispanic, compared to 82 percent in 2020. The population of color has grown from 11.1 percent in 2010 to 18.3 percent in 2020. Also from 2010 to 2020, the rate of increase of persons of color in North Dakota was much higher than nationally, a 91.6 percent increase in North Dakota compared to 24.9 percent nationally (ND Compass, 2021, Race - Demographics ). Immigrants (foreign-born) comprise 5 percent of North Dakota’s population and five percent of North Dakota’s population were native-born Americans with at least one immigrant parent (American Immigration Council, 2021, Immigrants in North Dakota).
Population growth has in part been due to an increase in fertility rates. According to 2020 NDDoH Division of Vital Records Data (NORTH DAKOTA (nd.gov)) , 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 aged 15-44 (National Center for Health Statistics, National Vital Statistics System, Natality; 2021 Births in the United States).
While the rate of teen pregnancies in North Dakota (15.5 per 1,000 females 15 to 19 years of age in 2019) (NORTH DAKOTA (nd.gov)) is lower than national rates (16.7 per 1,000 females 15 to 19 years of age in 2019) (About Teen Pregnancy | CDC), Native American teenagers in North Dakota had substantially higher rates than white teenagers. From 2016 to 2019, Native American teen pregnancies were almost four times that of White teenagers, 46 teenage births per 1,000 live births, compared to ten teenage births per 1,000 live births, respectively (Centers for Disease Control, WONDER).
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. Native Americans (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).
In 2020 state rates for infant mortality were similar to national averages, 6.0 deaths per 1,000 live births in North Dakota compared to 5.6 deaths per 100,000 live births nationally. The rate of low birth-rate infants is slightly better than national rates, six percent in North Dakota, compared to eight percent nationally (2020 County Health Rankings, North Dakota Report). 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, NORTH DAKOTA (nd.gov))
According to the 2017 Alan Guttmacher Institute Report on North Dakota, 29 per 1,000 pregnancies (31 %) were unintended (wanted later or unwanted pregnancy rate, women aged 15-44). Of the unintended pregnancies in North Dakota, 64 percent resulted in births and 22 percent in abortions.
The Alan Guttmacher Institute analyzed data from U.S. Census reports on the number and various characteristic of women, 2014-2019 ACS data on various demographic characteristics of women, and 2011-2015 National Survey of Family Growth to estimate the number of women who may have potential demand for contraceptive services. The report estimates there has been an 11 percent increase the number of women who likely need public support for contraceptive services and from 2010 to 2016. The report also estimates the number of women who likely need public support for contraceptive services and are uninsured declined by 6 percent from 8,700 in 2013 to 8,200 in 2016. (AGI, 2016, Publicly supported family planning services in the US) Three percent of the women 15 to 44 years old in North Dakota received Title X family planning services in 2019 (NDDoH, Family Planning).
Sexually Transmitted Disease, Human Immunodeficiency Virus (HIV), Hepatitis C Virus (HCV)
The 2020 North Dakota HIV, STI, TB & Viral Hepatitis Epidemiologic Profile cited 3,543 cases of chlamydia in the state, a rate of 464.9 cases per 100,000 persons and an 8.3 percent decline from 2019. Alternately, there was a 10 percent increase in gonorrhea cases from 2018 to 2019, 1,508 cases were reported (197.9 cases per 100,000 individuals). The Reservation Counties of Sioux, Benson and Rolette represented the highest incident of cases of both chlamydia and gonorrhea in the state. In 2020, there was a 6 percent decrease in syphilis cases reported in North Dakota, from 97 to 91 cases. Though the overall syphilis rate decreased, some races reported increased rates in 2020. Native American/Alaskan Natives reported 46.4 of infections per 100,000 persons and Black/African Americans had the greatest rate at 94.4 infections per 100,000 persons Five hundred (500) people with HIV/AIDS were known to be living in North Dakota as of December 31, 2020. Black/African Americans reported an incidence rate of 49.4 per 100,000. Additionally, 31 percent of all new cases were to foreign-born individuals. Hepatitis C Virus (HCV) infections declined by 12 percent from 2019 to 2020. There were 937 cases in 2019 and 823 cases in 2020. (NDDoH, 2020, 2020 Epidemiologic profile of HIV, STDs, TB and viral hepatitis in North Dakota).
Sexual Violence, Domestic Violence and Human Trafficking
In 2020 North Dakota’s state domestic and violence coalition served approximately 4,674 unduplicated new victims of domestic violence individuals and 999 unduplicated victims of sexual assault. (CAWS, Facts & Stats | CAWS North Dakota). Since its inception in 2015, the North Dakota Human Trafficking Task Force (NDHTTF 2021) has served 576 victims of human trafficking (71% adults, 29% minors). According to National Human trafficking hotline data between the years 2016 (19 cases reported) to 2020 (20 cases reported), the number of reported human trafficking cases has remained between 14 (2018) to 24 (2017) cases per years. For 2019, 22 cases were reported.
Substance Abuse and Behavioral Health
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 (2018-2019 National Survey on Drug Use and Health). The state ranks 12th nationally in suicides rates with 18 suicides per 100,000 (NVSS - National Vital Statistics System) and was the 11th leading cause of death in 2020 (NDDoH, Division of Vital Records).
In the 2019, according to the Youth Risk Behavior Survey (YRBS) approximately 38.3 percent of students (grades 9th-12th) in the state reported having had sexual intercourse. Approximately 29.6 percent of the students in the state reported being currently sexually active (had sexual intercourse with at least one person during the three months before the survey).
About 1 in 6 students (16.7 %) reported consuming alcohol or other drugs during their last sexual encounter. Additionally, 9.2 percent of students reported experiencing sexual violence one or more times in the 12 months before the survey. Among students who were sexually active, 8.4 percent did not use any pregnancy prevention methods during last sexual intercourse.
(YRSB, 2019, 2019ND-High-School-YRBS-Summary-Tables).
Income and Health Disparities
In 2019 approximately 1 in 9 North Dakota residents (10.6%) lived in poverty while 1 in 4 (24%) of single female householders lived in poverty. Although the state has experienced economic prosperity and has the 13th lowest unemployment rate in the nation at 3.2 percent (U.S. Bureau Labor Statistics, Unemployment Rates for States), there was no significant change in family poverty rates from 2009 to 2019 (11.9 % and 10.6%, respectively) (US Census Bureau, American Community Survey (ACS)).
In addition to income disparities, Native Americans populations have higher rates of diabetes, cancer, addiction, heart disease, incidents of SDTs, teen pregnancy and prenatal care. All 10 North Dakota counties identified as "least healthy," according to the 2018 County Health Rankings (County Health Rankings & Roadmaps), are either within a tribal reservation or designated as rural or frontier areas .
Approximately 91.8 percent of adults ages 18 to 64 had some form of health insurance. Five percent of children in the state had no health insurance (National Survey of Children's Health). While most women of reproductive age (15-49) had private health insurance (74%), nine percent were uninsured in 2019, and 13 percent were on Medicaid (ACS, 2019, American Community Survey).
The state's population is growing and changing. While still predominately white, North Dakota is becoming more diversified. And while the state has experienced strong economic conditions, there has been little change in household poverty rates. For some indicators, North Dakota compares favorably to national trends and other states. North Dakota’s fertility rates are higher than national average and teen pregnancies are lower. Alternately, the need for family planning and other behavioral and health services is clear. North Dakota has the highest rate of binge drinking among all the states and has seen the highest increase in suicide rates in the country. Further, health and income disparities among Native American populations are evident across nearly all indicators. The findings from this assessment will help to guide programs and policies to address the state’s need for family planning services.