Ted Holloway, MD Hoboken, Georgia pogosparky@aol.com

1. Public Policy & Perinatal Health Ted Holloway, MD Hoboken, Georgia pogosparky@aol.com

2. James W. Alley, M.D 1st Director of Public Health in Department of Human Resources Jim in Bolivia with malnourished 3 year old child with TB Jim as Public Health Director

3. Infant Mortality -Three Year Average 2007 – 2010 United Nations World Population Prospects report Rankings in 1994 25th United States 8.0 28th Cuba 9.4 United States in 34th Place

4. % of Georgia Children Living in Poverty 2010 * * Income < $23,050 for family of 4

5. Georgia Live Births 2000 - 2010

6. Georgia Births by Age of Mother 2010 65,085 White Births 44,132 Black Births 18 – 55 Years 10 – 17 Years

10. Georgia 2002 -2006 Contribution of Low Birthweight to Infant Mortality 11% of Georgia Births result in 80% of Infant Deaths

11. Birthweight Specific Infant Mortality Rate Georgia Birth Cohort 2007 Gordon R. Freymann, MPH Director, Office of Health Indicators forPlanning Georgia Department of Public Health

13. Live births by Race and Birthweight Georgia 2007 < 2500 Gram Births White 7.1% Black 14%

14. Analysis of Sociodemographic Risks Excess Rate Death Rate Education Sub-group Age White Group 3 ≤19 <13 years 13.3 8.3 Black Group 1 >20 >13 years 14.0 9.0 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 Alfred W. Brann, Jr., MD, Director Woodruff Health Sciences Center Emory University Brian McCarthy, MD, Principal Investigator Woodruff Health Sciences Center Emory University Georgia 2001 -2003 Deaths per 1,000 live births

15. Risk Factors for LBW Delivery • Unrecognized and poorly-controlled medical problems • African American mother • Previous history of LBW or SGA infant • Reproductive tract infections • Psychological stress • Short interpregnancy interval • Periodontal disease • Smoking • Substance Abuse Georgia Perinatal Task Force Report, 1998.

16. 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

17. Impact of Racial Disparity in Georgia • 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

18. 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% Goldenberg, R. L. and D. J. Rouse. "Prevention of premature birth." New England Journal of Medicine 1998, 339(5): 313-320. 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):

19. 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. 1 2 3 4 Neonatal Research Network- NICHD

20. Perinatal Policy Through Time

21. 1950’s • Era of Separate and Unequal • 25,000 African American home deliveries in Georgia per year • 1952 All My Babies Educational Film 1960’s • 1965 Medicaid and Medicare enacted • 1967 Early Periodic Screening, Diagnosis and Treatment 1970’s • 1973 • Dr. Lillian Blackmon’s study on Regional Systems for Georgia • MatPak (Maternal Package) program • 1974 • WIC Program • 1975 • Maternal Health Block Grant (Title V) • 1978 • MatPak changed to Maternal High Risk Program

22. 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 1982 – Arizona last state to enact Medicaid • 1986 • Medicaid requires states to cover pregnant women up to 100% of Poverty • 1989 • Medicaid increased income limit to 133% of Poverty 1990’s • 1996 • 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

23. 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 • 2009 • Maternal and Infant Council Eliminated • Public Health moved from DHR to DCH • Public Health cut over 13% ($25 Million since FY2009) • 2011 • Department of Public Health Established

24. Clinical Opinion American Journal of Obstetrics & Gynecology May 2102 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 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.

25. OBSTETRICS Preventing Low Birthweight: 25 years, prenatal risk, and the failure to reinvent prenatal care 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” Clinical Opinion American Journal of Obstetrics & Gynecology May 2102