ted holloway, md hoboken, georgia [email protected] public policy & perinatal health
TRANSCRIPT
Jim in Bolivia with malnourished 3 year old child with TB
James W. Alley, M.D1st Director of Public Health in Department of Human Resources
Jim as Public Health Director
Infant Mortality -Three Year Average 2007 – 2010United Nations World Population Prospects report
Rankings in 1994
25th United States 8.028th Cuba 9.4
United States in 34th Place
% of Georgia Children Living in Poverty 2010 *
* Income < $23,050 for family of 4
Georgia Live Births 2000 - 2010
Georgia Births by Age of Mother2010
65,085 White Births 44,132 Black Births
10 – 17 Years 18 – 55 Years
DEFINITIONS
Low Birthweight (LBW) : Birthweight of less than 2500 grams (5# 8 oz.)
Very Low Birthweight (VLBW) : Birthweight of less than 1500 grams (3# 5 oz.)
Small for Gestational Age (SGA) : Infants below expected weight for gestational age
DEFINITIONS
Infant Mortality Rate : For every 1,000 liveborn babies, the number that die before their first birthday
Neonatal Mortality Rate : For every 1,000 liveborn babies, the number that die before the 28th day of life
Post-neonatal Mortality Rate : For every 1,000 liveborn babies, the number that die between the 28th day of life and one year of age
Georgia 2002 -2006Contribution of Low Birthweight to Infant Mortality
11% of Georgia Births result in 80% of Infant Deaths
Weight Black White
0 – 499 Grams 717.4 602.4
500 – 999 Grams 270.7 329.1
1000 – 1499 Grams 51.1 50.3
1500 – 2499 Grams 14.0 11.7
2500 Grams and Larger 3.5 2.1
Birthweight Specific Infant Mortality RateGeorgia Birth Cohort 2007
Gordon R. Freymann, MPH Director, Office of Health Indicators for Planning Georgia Department of Public Health
Live births by Race and BirthweightGeorgia 2007
< 2500 Gram Births
White 7.1% Black 14%
Alfred W. Brann, Jr., MD, DirectorWoodruff Health Sciences CenterEmory University
Brian McCarthy, MD, Principal InvestigatorWoodruff Health Sciences Center
Emory University
Analysis of Sociodemographic Risks
Sub-group Age EducationDeathRate
ExcessRate
White Group 3 ≤19 <13 years 13.3 8.3
Black Group 1 >20 >13 years 14.0 9.0
Georgia 2001 -2003 Deaths per 1,000 live births
The highest risk/IMR white pregnancies (<20 yrs old, <13 yrs educ) are better than the lowest risk black pregnancies (>20 years old, > 13 years education
o Unrecognized and poorly-controlled medical problems
o African American mother
o Previous history of LBW or SGA infant
o Reproductive tract infections
o Psychological stress
o Short interpregnancy interval
o Periodontal disease
o Smoking
o Substance Abuse
Georgia Perinatal Task Force Report, 1998.
Risk Factors for LBW Delivery
Infants Born <1500 Grams
• 50% of Georgia’s infant mortality is from only 2% of the births- 1500 gm.
• We cannot identify the woman with a pregnancy that will end in her first preterm birth.
• The frequency of recurrence of a VLBW infant to a woman whose first pregnancy ended with a VLBW infant is:
- 8% for white women- 13% for black women- 2x for teenage girls
• African-American women in Georgia have twice the rate of LBW and 3-4 times the rate of VLBW delivery compared to Caucasian women, resulting in twice the rate of infant mortality
• Survival of VLBW infants has significantly improved in the last 25 years, but the prevalence of cerebral palsy has not changed.
• Georgia Perinatal Task Force Report, 1998
Impact of Racial Disparity in Georgia
Predictors of LBW Delivery
• No obstetrical or prenatal assessment or intervention has been successful in predicting or preventing a woman’s first preterm/LBW delivery (1);
• The single best predictor of a preterm/VLBW delivery:
• recurrent preterm/VLBW birth (2)
white 8%
black 13%
(1) Goldenberg, R. L. and D. J. Rouse. "Prevention of premature birth." New England Journal of Medicine 1998, 339(5): 313-320.
(2) Adams, M. M., L. D. Elam-Evans, H. G. Wilson and D. A. Gilbertz. "Rates of and factors associated with recurrence of preterm delivery." JAMA 2000, 283(12):
Central Nervous System Morbidity• There has been no change in the prevalence of cerebral palsy in children whose birth weight was less than 1500 gm.
• Infants less than 1000 gm. survive with significant handicapping conditions, including:
– Cerebral Palsy 17%– Mental Retardation 50%– Blindness / Hearing Loss 10%– Learning Disabilities 50%
• The average cost of the INITIAL HOSPITALIZATION of a VLBW is $49,000.
• The average cost for supporting an infant who survives with CEREBRAL PALSY is $500,000 over their lifetime.
3
1
2
4Neonatal Research Network- NICHD
Perinatal Policy Through Time
o Era of Separate and Unequalo 25,000 African American home deliveries in Georgia per yearo 1952 All My Babies Educational Film
1950’s
1960’so 1965 Medicaid and Medicare enactedo 1967 Early Periodic Screening, Diagnosis and Treatment
1970’so 1973
o Dr. Lillian Blackmon’s study on Regional Systems for Georgiao MatPak (Maternal Package) program
o 1974o WIC Program
o 1975o Maternal Health Block Grant (Title V)
o 1978o MatPak changed to Maternal High Risk Program
1980’s
1984 • Georgia passes bill to prevent “dumping” of pregnant women in
labor• Medicaid Needy expansion• Jim Alley & Jules Terry kick off 9 x 90 Campaign
1986 • Medicaid requires states to cover pregnant women up to
100% of Poverty1989
• Medicaid increased income limit to 133% of Poverty
1990’s1996
• Mother’s & Babies Protection Act requires minimum stays after delivery• High Risk Program changed to Babies Born Healthy
1997• PeachCare for Kids covers children up to 235% of Poverty
1982 – Arizona last state to enact Medicaid
2000’s
2006 Medicaid becomes a managed care program with contracts to CMOs. Now pre-authorization was required for referrals to tertiary centers, level III ultrasounds, etc. Perinatal Case Management, done previously almost exclusively by county Health Departments, was done by the CMOs
2009Maternal and Infant Council EliminatedPublic Health moved from DHR to DCHPublic Health cut over 13% ($25 Million since FY2009)
2011 Department of Public Health Established
Preventing Low Birthweight: 25 years, prenatal risk, and the failure to reinvent prenatal care
Elizabeth E. Krans, MD, MSc; Matthew M. Davis, MD, MAPP
In 2010, Preventing Low Birthweight celebrated it 25th anniversary. The report, one of the most
influential policy statements ever issued regarding obstetric health care delivery, linked prenatal care to a
reduction in low birthweight (LBW). Medicaid coverage for pre- natal care services was subsequently
expanded and resulted in increased prenatal care utilization. However, the rate of LBW failed to decrease.
This well-intentioned expansion of prenatal care services did not change the structure of prenatal care. A
single, standardized prenatal care model, largely ineffective in the prevention of LBW, was expanded to a
heterogeneous group of patients with a variety of medical and psychosocial risk factors. Reinventing
prenatal care as a flexible model, with content, frequency, and timing tailored to maternal and fetal risk,
may improve adverse birth outcomes. Risk-appropriate prenatal care may improve the effectiveness of
prenatal care for high-risk patients and the efficiency of prenatal care delivery for low-risk patients.
OBSTETRICS
Preventing Low Birthweight: 25 years, prenatal risk, and the failure to reinvent prenatal care
Elizabeth E. Krans, MD, MSc; Matthew M. Davis, MD, MAPP
Clinical Opinion American Journal of Obstetrics & Gynecology May 2102
Conclusion:
the Report “challenged the OB community to reinvent prenatal care as a targeted intervention – a flexible model where content, frequency and timing were tailored to maternal and fetal risk factors. Instead, efforts to apply the report’s findings led to expanded but undifferentiated coverage for pregnant women….. This well intentioned, but ultimately inefficient aned ineffectual, policy meant that the IOM Committee’s call to revise the prenatal care model were overshadowed by the comparatively easy solution of giving more of the same care to all patients”
OBSTETRICS
Preventing Low Birthweight: 25 years, prenatal risk, and the failure to reinvent prenatal care
Clinical Opinion American Journal of Obstetrics & Gynecology May 2102
