HD11 - A Final Report of the State Perinatal Services Advisory Council on the High Rate of Infant Mortality in Virginia
Executive Summary: As requested by House Joint Resolution No. 218 (1981), the State Perinatal Services Advisory Council has conducted a two-year study to identify factors related to Virginia's high infant mortality rate. The Council's review of Virginia's current perinatal health statistics revealed the following significant findings: • In 1981, Virginia's infant mortality rate of 12.6 per 1,000 live births was worse than that of 31 other states in the nation. • Virginia's infant mortality rate has exceeded the national rate for the past 11 years, with the exception of the year 1978. • Virginia's perinatal mortality rate, according to the most recent national data, has exceeded the national rate during the period 1970-78. • In Virginia, almost 85% of the infant deaths under one week of age occur in low birth weight newborns (5 lbs., 8 oz. or less). The chances for surviving the first week of life decrease as the birth weight decreases. • In Virginia, approximately 70% of all natural fetal deaths 28 weeks gestation and over were of low weight. It is also significant that 30% of the fetal deaths were at least 36 weeks gestation and weighed more than 5 lbs., 8 oz.; this is an unacceptably high proportion of deaths occurring in term-sized fetuses. Because low weight is an underlying factor in most newborn deaths under one week and in natural fetal deaths of 28 weeks gestation and over, the Council concludes that weight is the most significant factor in pregnancy outcome; if low birth weight can be prevented, an infant's chances for survival will be dramatically improved. The Council's analysis of birth and infant death data revealed that mothers having the following characteristics are at greater risk of delivering a low birth weight infant: - No prenatal care received - Not married to the father of the infant - Nonwhite - Under eighteen years of age - Less than a high school education Specifically, mothers with any one of these characteristics are 2-4 times as likely to deliver a low birth weight infant than mothers without such characteristics. Among these characteristics, no prenatal care received is the most significant factor; mothers who receive no prenatal care are 4 times as likely to deliver a low birth weight infant than mothers who receive care. Although other factors such as economic status, nutrition, smoking, and medical complications are recognized as also influencing pregnancy outcome, the Council's identification of factors was limited to an assessment of the data available on birth, death, and fetal death certificates. An assessment of the current perinatal care system, including family planning, prenatal, labor and delivery, and newborn services, was conducted to identify deficiencies which may contribute to Virginia's high infant mortality. The following problems, not in order of priority, were significant among those identified as hindering the obtainment of quality care by expectant mothers and newborns and contributing to poor pregnancy outcome and infant survival. • Difficulty in getting the teenager into the health care system prior to beginning of sexual activity or early in pregnancy. • Limited accessibility of special tests and diagnostic procedures for at-risk pregnant women receiving care in health department prenatal clinics. • Lack of continuity of care at time of delivery for many low-income prenatal patients who are unable to secure a delivering physician and/or hospital prior to time of delivery. • Inadequate educational services for the public, patients, and providers. • Nurse shortages in neonatal intensive care units. • Lack of a formal system of regionalized care, including no formal designation of regional centers, and no formal mechanisms for referral of patients, for newborn transport, or for patient and provider education. Based on findings of the assessment of health status and the perinatal care system, the Council determined that a reduction in infant mortality would be achieved primarily by prevention of low birth weight births and by increasing the chances of survival for those low birth weight infants that are born. The Council recommends that these two goals be accomplished through the following strategies: 1. Ensure availability and accessibility of prevention services, such as family planning, and education programs for patients/consumers, health care practitioners, and the public. 2. Ensure availability and accessibility of both routine and high-risk prenatal, labor and delivery, and newborn services. Since the successful implementation of these strategies depends upon the further development of a formal regionalized perinatal care system in Virginia, the Council presents specific recommendations for the development of such a system. Recommendations are directed to the Department of Health and other agencies of state government, to the private sector provider organizations, and to regional centers that are to be designated to coordinate care in their regions. Significant among the recommendations is the following: • The Department of Health should assume the lead responsibility for developing and implementing educational and public information programs to promote awareness of specific perinatal health problems, the need for perinatal care, and the impact of lifestyle risk factors on the outcome of pregnancy. Specifically, all public school systems should be strongly encouraged to implement family life education curriculum. Educational efforts should be carried out in connection with the Department of Mental Health and Mental Retardation, the Department of Education, regional perinatal centers, local health departments, Community Services Boards, and other private and public agencies involved in perinatal care. • The Department of Health, through its local health departments, should be responsible for identifying those low-income maternity patients and their newborn who are receiving inadequate prenatal, delivery, and routine newborn services. For such patients, the Department should, if financially feasible, establish formal contractual arrangements with local providers who are available and willing to contract for provision of adequate care. • The Department of Health should expand the existing neonatal hospitalization program to ensure that reimbursement for neonatal special care, both intensive and intermediate, is adequate to cover the cost of care provided. • The Department of Health should develop and implement a process for formal designation of regional perinatal centers in Virginia, with priority attention directed toward the establishment of an intermediate level perinatal referral center having neonatal transport capabilities, for the far Southwest area of the state (Perinatal Region I). • Professional organizations represented on the Perinatal Council should strongly encourage their respective private sector providers of perinatal care to utilize the patient care guidelines recommended by the Council concerning assessment of risk, referral and transport practices, and inpatient and ambulatory care for mothers and newborns. • Designated regional perinatal centers should provide high-risk perinatal care and ensure that transport, education, and consultation services are available within their regions. Based on an analysis of the current cost of providing adequate perinatal services within Virginia, the Council estimates that an additional $13.2 million would be required annually to ensure that a regionalized system of care is in place and that the proposed recommendations summarized above can be implemented. It is the council's firm belief that the expenditure of such funds in a manner consistent with this report's recommendations will result in significant improvements in the health status and health care system for Virginia's mothers and newborns. Accordingly, the Council recommends that the Governor and the Virginia General Assembly designate perinatal care as a major priority for new funding and should support increased appropriations, over time, for perinatal services. The Council recommends that appropriations for perinatal care be phased in over a four-year period. |
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