RD489 - 2016 Thriving Infants Report – November 15, 2016
In Item 294 of the 2016 Appropriation Act, the Virginia General Assembly directed that:
“the Virginia Department of Health shall report on state policies and programs that would improve birth outcomes in the Commonwealth and make recommendations to the General Assembly. The department shall evaluate and report on the most effective models for improving birth outcomes, reducing teen pregnancy, reducing unintended pregnancies, and improving the spacing between births.”
Improving Birth Outcomes
Virginia’s Plan for Well-Being (The Plan) is a call to action for Virginians to create and sustain conditions that support health and well-being. It provides an outline to guide the development of projects, programs, and policies to advance Virginia’s health. One of The Plan’s key aims is to ensure a strong start for children. The well-being of children determines the health of families and communities and can help predict future public health challenges. To give children a strong start, The Plan recommends a focus on helping Virginians plan their pregnancies and eliminating the racial disparity in infant mortality as foundational to achieving the aim. Strategies include increasing access to quality family planning services for all women of child-bearing age; expanding access to and use of preconception health services to enable optimal health prior to pregnancy; eliminating early elective deliveries; and expanding home visiting and family support programs.
A comprehensive approach to improving birth outcomes, reducing teen pregnancy, reducing unintended pregnancies, and improving birth spacing that aligns with Virginia’s Plan for Well-Being can be developed using the Health Impact Pyramid. The Health Impact Pyramid categorizes public health interventions according to both population health impact and individual effort needed. Within this framework, there are seven domains for improving birth outcomes: Implement Health Promotion Efforts; Ensure Quality of Care for All Women and Infants; Improve Maternal Risk Screening for All Women of Reproductive Age; Enhance Service Integration for Women and infants; Improve Access to Health Care for Women Before, During and After Pregnancy; Develop Data Systems to Understand and inform Efforts; and Assure Conditions that Promote Health Opportunity.
Implement Health Promotion Efforts
Preconception health behaviors that can affect pregnancy and infant related health include substance use. Smoking by pregnant women is associated with 30 percent of small-for-gestational age infants, 10 percent of preterm infants and 5 percent of infant deaths (Association of Maternal and Child Health Programs, 2012). In Virginia, 16.4% of women ages 18-44 are current smokers (BRFSS, 2015)(BRFSS 2015) and 9.8% of women smoke during pregnancy (PRAMS, 2012-2013)(PRAMS 2012-2013). Smoking prevention and cessation efforts can positively impact birth outcomes. QuitNow Virginia, the telephone and on-line tobacco cessation counseling service available to Virginians 13 years and older, demonstrates a return on investment of $10.16 for every $1 spent on the quitline services and tobacco cessation media. This represents a saving of $2.1 million in medical expenses; $962,000 in lost productivity; $7.1 million in worker’s compensation; and $328,000 in exposure to second hand smoke. The U.S. Centers for Diseases Control and Prevention (CDC) has recommended that Virginia’s minimum annual investment in its state quitline should be $21,000,000, which would provide comprehensive services to 105,000, or 8.6%, of Virginia smokers. FY15 funding for QuitNow Virginia was approximately $350,000, only 1.7% of the recommended level, with CDC as the sole source of funding.
Enhance Service Integration for Women and infants
Integrated service delivery is an approach to meet the health and well-being needs of women, children and families by providing access to a quality, comprehensive and coordinated community-based system of services (Association of Maternal and Child Health Programs, 2012). For women of reproductive age, this may mean providing and coordinating maternity, reproductive health, primary care and child health services. Through comprehensive home visiting programs, nurses, social workers, and community health workers work with at-risk families to provide education and links to services that positively impact maternal and newborn health, improve school readiness, and prevent child abuse. Home visiting programs can help reduce long-term costs and promote healthy social and emotional development in later years (Association of Maternal and Child Health Programs, 2012). Virginia invests over $30 million in early childhood/home visiting (Virginia Home Visiting Consortium, 2016). Currently, the Virginia Home Visiting Consortium serves 9,066 families in 110 communities, meeting 7.5% of the estimated need. The highest quality nurse home visiting programs can generate returns of $5.70 for every $1.00 spent, in reduced mental health and criminal justice costs, decreased dependence on welfare, and increased employment (The Pew Center on States, 2004). This translates into a total benefit to society of more than $41,000 per family served (Karoly, Kilburn, & Cannon, 2005).
Reducing Teen Pregnancy, Unintended Pregnancy and Improving Birth Spacing
Almost half of all pregnancies in the United States are unintended. Unintended pregnancies are associated with several negative health and economic consequences, including delays in initiating prenatal care; reduced likelihood of breastfeeding; maternal depression; and increased risk of physical violence during pregnancy (Healthy People 2020, 2016). The negative consequences associated with unintended pregnancies are greater for teen parents and their children. Comprehensive family planning and preconception health lead to improved birth outcomes, which are associated with better health and cognition as children grow. Family planning services include contraceptive and broader reproductive health services, such as patient education and counseling; breast and cervical cancer screening; sexually transmitted infection prevention education, counseling and testing; and pregnancy diagnosis and counseling (Healthy People 2020, 2016). Each year in the U.S., publicly-funded family planning services prevent 1.94 million unintended pregnancies, including 400,000 teen pregnancies (Healthy People 2020, 2016). Preconception care for females and males includes health screenings, counseling and clinical services that enable them to become as healthy as possible before a pregnancy. The Virginia Department of Health(VDH) has provided family planning services through local health departments for more than 40 years using local cooperative budgets and the Title X family planning grant. In 2015, VDH Title X served 52, 598 women. While annual funding allocations for Title X have decreased by 26 percent (from $4,826,614 in 2010 to $3,594,600 in 2016) VDH has maintained all of its 132 service sites and remains committed to its role as a safety-net provider of family planning services.
Innovative models of family planning service delivery focused on reducing unintended pregnancies and teen pregnancies have recently come to national attention. The Colorado Department of Public Health and Environment’s (CDPHE) Colorado Family Planning Initiative(CFPI) increased funding to Title X family planning clinics to improve the program’s operations, facilitate health care provider training and reduce the costs of the most effective forms of contraception, specifically long acting reversible contraceptives (LARC), for women in need. When LARCs (i.e., intrauterine devices and implants) became more readily available in Colorado between 2009-2013, the birth rate fell by 40% among women ages 15-19 and 9% among women ages 20-24, and the number of repeat teen births dropped by 53% from 2009-2013. In addition, the abortion rate fell by 42% among women ages 15-19 and 18% among women ages 20-24 (CDPHE, 2016). Similarly, the CHOICE project was a research study conducted by Washington University in St. Louis to remove the financial barriers to contraception, promote the most effective methods of birth control, and reduce unintended pregnancy. As part of this project, women using LARC had the highest satisfaction at 1-year follow-up. Women using LARC or a birth control shot had the lowest unintended pregnancy rates at one, two, and three years of follow-up.
In Virginia, there are opportunities to build on work currently underway to improve birth outcomes, prevent teen pregnancy, reduce unintended pregnancy, and improve birth spacing through implementation of programs, policies, and infrastructure. The General Assembly may wish to consider implementing the following recommendations intended to improve pregnancy outcomes in Virginia:
1. Authorize use of state funds to develop a pilot program in Virginia Department of Health Title X family planning clinics to increase education about reproductive choices available to women and to expand access to long acting reversible contraception (LARC). Appropriate $3,000,000 the first year and $6,000,000 the second year from the Temporary Assistance for Needy Families (TANF) block grant and provide one position for the purpose of developing the pilot program. The pilot should expand family planning services to an additional 30,000 women in the state, enabling them to choose the most effective contraceptives. A report should be submitted to the Governor, Chairmen of the House Appropriations and Senate Finance Committees, Secretary of Health and Human Resources, and Director, Department of Planning and Budget that details program results and actual program expenditures no later than October 1 of each year for the preceding fiscal year ending June 30.
2. Appropriate state funds to support QuitNow Virginia, the tobacco cessation counseling telephone and online service administered by the Virginia Department of Health, sufficient to cover 100% of the administrative cost of serving Medicaid beneficiaries receiving QuitNow services
3. Appropriate state funds to expand home visiting services to at least 20% of the families in need across the Commonwealth, working closely with the Virginia Home Visiting Consortium to coordinate the home visiting services.