SD13 - Relating to Infant Mortality
Executive Summary: In 1985, one out of every 87 infants born to Virginia residents died before reaching its first birthday. An infant's chance of survival is better in 38 other states than in Virginia. Low birthweight is the primary factor associated with infant mortality; infants weighing 2 lbs, 12 oz or less are over 100 times more likely to die in the first 28 days of life. Those low weight infants who survive are very likely to suffer mental or physical handicaps. In addition to the human costs, infant mortality has high economic costs. Many low birthweight infants require costly neonatal intensive care. Total postnatal health care costs for very low birthweight infants are estimated to be between $20,000 and $100,000 per infant, compared to an estimated $550 for a normal weight infant without complications. There are also expensive costs associated with long term care for those low birthweight infants who survive with physical and/or neurological impairments; the cost of education/residential care for a child with severe handicaps may exceed $450,000. Many of the human and financial costs of infant mortality are preventable. Comprehensive prenatal care is the single, most significant factor in preventing low birthweight and enhancing a newborn's health. The cost-effectiveness of prenatal care has been demonstrated. Oregon recently determined that it could provide prenatal care to 149 women for the same amount that it costs to treat five high-risk premature infants. The Institute of Medicine estimates that for every dollar spent providing comprehensive prenatal care to high-risk women, a savings of $3.38 in the treatment of low birthweight infants could be realized. These medical treatment cost-savings represent only a small portion of the overall savings, which include those associated with special education, long term care and other social and human resource expenses. Governors Robb and Baliles have both taken an active interest in reducing Virginia's infant mortality rate. Both have highlighted it in their State of the Commonwealth speeches and both have included it in their budget requests. The first Governor's Conference of the Baliles administration was convened to address infant mortality in Virginia. The Virginia General Assembly has also recognized the human and economic costs of Virginia's infant death rate. In the past few years, both houses have appropriated additional money for prenatal care, health services and prevention programs such as Resource Mothers and Preterm Birth Prevention. Senate Joint Resolution #39 addresses five concerns identified by Virginia's Legislative Task Force on Infant Mortality, chaired by Senator Robert C. Scott (Newport News). The five issues and an overview of study findings and recommendations follow. 1. Facilitate statewide access to apnea monitors through Medicaid purchase, rental, or contract. Due to the apparent lack of adequate controls, and questions raised concerning justification for use of apnea monitors on an outpatient basis, Medicaid payment for this service was terminated in the early 1980's. The only such outpatient service provided under the present Medicaid program is testing for apnea on a diagnostic non-continuous basis. The use of monitoring in conjunction with intensive respiratory therapy may also be covered. During the past year, Department of Medical Assistance Services staff have met with interested parties to consider possible coverage of apnea monitoring services on an outpatient basis. Research conducted for the purpose of this resolution revealed that the efficacy of home apnea monitoring has not yet been determined nationally. A recent national consensus conference confirmed these study findings. The Department recommends that study of coverage of apnea monitoring be continued through the Governor's Task Force on Indigent Care. 2. Study the personnel needs in those areas of Virginia having the highest incidences of low birthweight and infant mortality to determine minimally optimal staffing requirements of local health departments, and develop a plan for effective utilization of personnel in providing outreach, family planning, prenatal, perinatal, and neonatal services. Personnel needs in the twenty public health districts having rates of infant mortality or low birthweight (or both) that exceeded the state average were studied through utilization of the Nurse Management Model, a computerized tool for identifying public health staff requirements. The analysis revealed a need for 203 positions in these districts to provide family planning and maternity services. Suggested staff distribution follows: Direct Care Providers public health nurses: 80 certified nurse practitioners (primarily nurse midwives): 20 nutritionists: 20 outreach workers: 20 clerical staff: 20 health educators: 19 physicians: 6 Total Direct Care Providers: 185 Support Staff managers/supervisors (primarily nurses): 18 Total Direct Care Providers and Support Staff: 203 These staff needs require adjustment based on local conditions, including consideration of other local providers serving the same patient population in addition to the health department. A significant barrier to the provision of quality health department family planning and maternity services is the lack of adequate full-time positions at the local level. The use of hourly positions often results in the inability to attract the most qualified candidates and in high staff turnover rates. 3. Establish the case management system for obstetric patients served by local health departments. Effective case management requires the formal designation of public health nurses as case managers for a specific number of patients under their care. Because of limited nursing staff, such formal designations are not made in all health departments. As a result of this study, the Department has developed guidelines for distribution to all health departments to assist them in reviewing their current case management arrangements. These guidelines encourage local health departments to formally designate a case manager for each maternity patient. The Department has identified various systemic barriers which must be overcome to ensure effective case management, including: lack of sufficient number of full-time health department nursing positions; difficulty of securing a delivering physician for health department maternity patients; ineffective interagency communication and cooperation; and difficulty in ensuring adequate transportation for health department patients to and from medical providers. 4. Initiate the necessary process by which Virginia may participate fully in the Center for Disease Control's (CDC) Nutrition Surveillance System. Participation in the CDC Nutrition Surveillance System requires the development of a data processing program that will transcribe the Virginia Special Supplemental Food Program for Women, Infants, and Children (WIC) data into the format required by CDC. Development and testing of the program are expected to be completed by the end of fiscal year 1987. Once in full operation, the WIC Program will receive monthly CDC nutrition surveillance reports at no charge. 5. Compile and disseminate data related to pregnancy outcome in a timely manner. Virginia data related to pregnancy outcome are compiled; in a manner that ensures accuracy and completeness and are distributed once finalized. A number of activities are underway or planned which will expedite the compilation and distribution of Virginia data, including: negotiations with states to exchange computer tapes in addition to copies of records; more thorough follow-up of incomplete or missing records at time of filing; modernization of the existing computer system by direct entry of data into the computer terminal; and the placement of microcomputers in hospitals for direct entry of birth certificate information. Most states publish their annual statistical reports later than Virginia. Those states that publish earlier than Virginia do not perform extensive follow-up for completeness and accuracy. |
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