Birth Outcomes

Promoting Healthy Birth Outcomes

Although New York has made tremendous strides in improving birth outcomes, key perinatal indicators have remained stagnant or have worsened. These poor outcomes result from complex medical, psychological, social and environmental factors that can present significant public health challenges to a state as diverse as New York. Some of the most significant factors that influence birth outcomes occur before pregnancy, such as nutritional status and other health behaviors. Taking a life course approach which involves encouraging healthy behaviors from early childhood through adulthood may be key in improving birth outcomes.

In 2008, the percent of women giving birth in NYS who received early prenatal care was 66.5%, significantly below the Healthy People 2020 goal of 90%. There has also been little change in low birthweight rates for the past decade. In 2008, the prevalence of low birthweight was 8.2% of all births, higher than the Healthy People 2020 goal of 7.8 % of all births. The infant mortality rate has steadily declined, the 2008 rate of 5.4 deaths per 1,000 births was below the Healthy People 2020 goal of 6.0 deaths per 1,000 births. Data also show that disparities in birth outcomes are often significant. For example, in 2008, 12.5% of black infants were born low birthweight, and black women were more likely to have preterm births than white and Hispanic women.

Poor pregnancy outcomes, including low birthweight, preterm births and infant mortality, are associated with late or no prenatal care, unplanned pregnancy, cigarette smoking, alcohol and other drug use, being HIV positive, short interpregnancy spacing, chronic diseases, obesity, maternal age, poor nutrition and low socioeconomic status. Recent studies point to associations between oral infection, particularly gum disease, and preterm, low-weight births. Pregnant women with periodontal (gum) disease may be seven times more likely to have babies born too early and too small.2 The exact connection between poor oral health and adverse birth outcomes is still being studied. The cost of preterm births in the United States was estimated to be $26.2 billion in 2005.

 

References

  1. Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion, Divison of Oral Health. Links Between Oral and General Health. U.S. Department of Health and Human Services. Office of the Surgeon General. October 4, 2004.
  2. American Academy of Periodontology. Baby Steps to Healthy Pregnancy and On-Time Delivery. AAP Oral Health Tips. March 10, 2008.

Objectives

  • By the year 2013, increase the percentage of women in New York who have received prenatal care in the first trimester to at least 90 percent. (Baseline: 74.6%, Vital Statistics, 2006)
  • By the year 2013, reduce the percent of New York births that are low birthweight (<2,500 grams) to no more than 5%. (Baseline: 8.3%, Vital Statistics, 2006)
  • By the year 2013, reduce New York's rate of infant deaths to no more than 4.5 deaths per 1,000 births. (Baseline: 5.8/1,000, Vital Statistics, 2006)

Program Goal

  • By the year 2013, reduce the percent of late preterm births (34-36 weeks gestation) to no more than 6.4%. (Baseline: 8.3%, Vital Statistics, 2006)

Indicators for Tracking Public Health Priority Areas

Each community's progress towards reaching these Prevention Agenda Objectives will be tracked so members can see how close each community is to meeting the objectives.

Data and Statistics

New York State Department of Health Programs

Perinatal Health in New York State.
In NYS, a multi-pronged approach has been taken to provide perinatal services and improve maternal and infant outcomes. Improving outcomes requires both a hospital-based and community-based public health approach at many levels, including broad based outreach and regional approaches to identify gaps and barriers in the service system, as well as one-on-one direct services and outreach to the highest risk populations of the state. The system of clinical services also must fully support quality comprehensive care for all New Yorkers.
Perinatal Regionalization Program
The NYS system of regionalized perinatal services includes four levels of perinatal care provided by the hospitals within a region ranging from basic, uncomplicated deliveries (Level I hospitals), mothers and babies with the most complex, critical problems (Level III hospitals and Regional Perinatal Centers). The regional systems are led by Regional Perinatal Centers which, in addition to providing care to the highest risk mothers and babies, provide education and data support to their affiliate hospitals, and lead quality improvement activities in their regions.
The New York State Medicaid Services for Pregnant Women
New York’s Medicaid program requires comprehensive prenatal care in both the managed care and fee-for-service delivery systems. Qualified clinics and practitioners in both systems offer complete pregnancy care and other health services to NYS women and teens who meet certain income guidelines. Find where to go to apply for prenatal care coverage.
In areas of the state without prenatal clinics, eligible practitioners provide complete medical pregnancy services in private offices with other ancillary services provided by Health Supportive Services Providers (HSSP). Physicians are connected with HSSPs to ensure all women receive complete pregnancy care. The New York Medicaid program now offers other critical services for pregnant women and for certain other Medicaid eligible recipients:
  • Smoking cessation counseling (effective January 1, 2009). See October 2008 Medicaid Update.
  • Mental health counseling in Article 28 clinics provided by Licensed Social Workers for adolescents, children and pregnant and post-partum individuals.
  • After-hours access (effective January 1, 2009) for hospital outpatient clinics and for diagnostic and treatment centers (effective March 1, 2009). An add-on payment is available for visits which are scheduled and occur on evenings, weekends and holidays as defined by the NYSDOH.
  • Asthma and Diabetes Self Management Training (effective January 1, 2009 for physicians' offices and hospital outpatient departments and March 1, 2009 for Diagnostic and Treatment Centers). Medicaid reimbursement will be available for asthma and diabetes self management training services for Medicaid beneficiaries diagnosed with asthma and diabetes.
Expanded and Streamlined Medicaid Eligibility for Pregnant Women
The NYS Medicaid program offers pregnant women Medicaid coverage at the first prenatal visit based upon a brief presumptive eligibility determination by a qualified prenatal care provider, assistance with completion of a full Medicaid application with no resource documentation requirements, and expanded eligibility for pregnant women and infants younger than one year of age with family incomes at or below 200% of the federal poverty level. See Medicaid (Annual and Monthly) Income Levels for Pregnant
Growing Up Healthy Hotline
A toll-free hotline (1-800-522-5006) operates 24-hours per day, seven days per week and provides information and referral for individuals, including teens, about pregnancy care services, family planning, health care, nutrition and other health and human services. Information is available in English and Spanish with other languages available, as needed.
Comprehensive Prenatal-Perinatal Services Networks
These networks are community-based organizations that help the perinatal service system at the local level to improve pregnancy outcomes and promote better health for pregnant and reproductive age women, infants, and children. Networks partner with consortia of local health and human service providers and consumers to identify and address issues. There are currently 16 networks across the state that target areas at highest risk for poor pregnancy outcomes.
Community Health Worker Program
The Community Health Worker Program (CHWP) provides one-on-one outreach, education and home visiting services to pregnant and parenting women and families at highest risk for poor health outcomes, particularly low birthweight infants and infant deaths. Community health workers are trained to provide referrals for a wide range of services, and to provide support and assistance for families trying to obtain needed services. There are currently 23 CHWPs throughout the state.
The Healthy Mom – Healthy Baby Prenatal and Postpartum Home Visiting Program
This program will ensure early identification of high risk pregnant women and newborns through targeted community outreach and provide or coordinate health education, health services, referrals and other supportive services, including home visiting. Communities will develop and implement an organized system of health and home visiting services to assess the women’s and infant’s need for health care and services, and help these families obtain appropriate services. The NYS Department of Health has awarded funding to six local health departments whose residents are at highest risk of poor prenatal outcomes, including Erie, Monroe, Onondaga, Westchester, NYC (Bronx) and Orange counties.
The Nurse-Family Partnership
The Nurse-Family Partnership (NFP) is a professional (nurse-led) home visiting program targeted to low-income, first-time mothers designed to improve pregnancy outcomes, children’s subsequent health and development, and parents’ economic self-sufficiency. The Department supports enhancement of existing programs through one-time TANF (Temporary Assistance to Needy Families) funding through an MOU with the Office of Temporary and Disability Assistance. Nurse-Family Partnership programs are located in Onondaga and Monroe counties, and throughout New York City.
First Time Motherhood / New Parent Initiative
In 2010, the Department was awarded a new grant for $500,000 per year, for three years, under HRSA’s First Time Motherhood/New Parent Initiative grant program. The purpose is to increase awareness of resources available to women preparing for childbirth and to new parents. Specific objectives focus on improving perinatal health outcomes and strengthening resources for newly-parenting families by increasing awareness of the importance of preconception/interconception health, increasing health care professionals' capacity to provide preconception and interconception health care services, and increasing awareness of the importance of preconception health behaviors among young low income Black women and men.
The Maternal, Infant and Early Childhood Home Visiting Program
The Patient Protection and Affordable Care Act (ACA) of 2010, created the Maternal, Infant and Early Childhood Home Visiting Program (MIECHVP), a new initiative supported by a grant from HRSA designed to improve health and development outcomes for at-risk children and families through evidence-based home visiting programs. The Department has completed a comprehensive statewide needs assessment, which looked at county-level indicators by both rates and number of cases, as required by the grant to identify communities in the state with concentrations of premature birth, low-birth weight infants and infant mortality. The Department is assessing the same set of indicators at the ZIP code level to identify specific communities where risk is greatest.
Regional Perinatal Forums, Regional Perinatal Centers and Comprehensive Prenatal-Perinatal Services Networks
These groups bring together key perinatal stakeholders and other committed community service providers to identify and address barriers to improving birth outcomes in their geographic areas. This partnership brings the medical and the human services communities together in seeking regional solutions to identified problems.
Comprehensive Family Planning and Reproductive Health Care Services
The NYSDOH provides accessible reproductive health care services to women and men, especially low-income individuals and those without health insurance, through a network of statewide agencies. Services include contraceptive (birth control) education, counseling and methods to reduce unintended pregnancies and to improve birth spacing and outcomes; testing and treatment for sexually transmitted infections; routine screening for breast and cervical cancer; and health education in community settings to promote reproductive health, prevent unintended pregnancy and promote access to reproductive and preventive health services.

Strategies –The Evidence Base for Effective Interventions

Folic Acid Supplementation and Fortification Reduces Number of Babies With Neural Tube Defects
Folate taken before pregnancy and in the first two months of gestation can help prevent major birth defects of a baby's brain and spine. The Task Force on Community Preventive Services recommends community-wide campaigns to increase the use of supplements containing folic acid by women of childbearing age and folic acid fortification of food products.
Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes
Screening for depression, one of the most common perinatal complications, is feasible and fairly accurate.
A Pocket Guide to Adult HIV/AIDS Treatment: Companion to A Guide to Primary Care of People with HIV/AIDS, August 2004 Edition
The 58-page pocket guide is a resource for physicians and other health professionals in the appropriate treatment of patients with HIV/AIDS. A Guide to Primary Care of People with HIV/AIDS, 2004 Edition, has drug information tables, adult antiretroviral therapy tables, pregnancy tables, a three-step provider process for HIV prevention, and opportunistic infection tables focused on tuberculosis.
Primary Care Interventions to Support Breastfeeding
There is convincing evidence that breastfeeding provides substantial health benefits for children and adequate evidence that breastfeeding provides moderate health benefits for mothers. The promotion and support of breastfeeding may be accomplished through interventions over the course of pregnancy around the time of delivery, and after birth while breastfeeding is underway. Interventions may include breastfeeding education for mothers and families, direct support of mothers during breastfeeding observations, and the training of health professional staff about breastfeeding and techniques for breastfeeding support. Evidence suggests that interventions including both prenatal and postnatal components may be the most effective at increasing breastfeeding duration. Many successful programs include peer support, prenatal breastfeeding education, or both.
Recommendations to Improve Preconception Health and Health Care
Improving women’s health before pregnancy is essential to improve birth outcomes. The Centers for Disease Control and Prevention has outlined ten recommendations for improving women’s preconception health and thereby improving birth outcomes, including emphasizing the importance of personal responsibility; increasing public awareness, risk assessment, education and counseling on the importance of behaviors that impact preconception health; increasing interventions for women with identified risks; providing interconception interventions for women with adverse outcomes; expanding health insurance coverage; and increasing public health surveillance and research to monitor preconception health.
Lee E, Mitchell-Hertzfeld SD, Lowenfels AA, Greene R, Dorabawila V, DuMont KA. Reducing low birth weight through home visitation: a randomized controlled trial. Am J Prev Med. 2009 Feb;36(2):154-60
As part of a larger randomized control trial, this study examined the effects of home-visitation services on low birthweight (LBW) deliveries. The study found that the risk of delivering LBW babies was significantly lower for participants in the group receiving prenatal home visits with a focus on social support, health education, and better access to services, suggesting that this approach holds promise for reducing LBW deliveries among at-risk women and adolescents.

Reports and Resources

Families and Children
This U.S. Department of Health and Human Services website has a wealth of information on a broad range of topics related to families and children.
March of Dimes
Website contains information for professionals, researchers and community.
Healthy People 2010/2020: Maternal, Infant and Child Health
Information related to maternal, infant, and child health goals and objectives for Healthy People 2010/2020 is found throughout the MCH Library Web site.

Return on Investment

Henderson JW. The cost effectiveness of prenatal care. Health Care Financ Rev. 1994 Summer;15(4):21-32.
This study examined the association between prenatal care and birth outcomes and the implications for hospital costs for newborn infants. The net expected hospital cost savings for females who received prenatal care was over $1,000.
Behrman RE, Butler AS ed. Preterm birth: causes, consequences and prevention. Washington, DC: National Academies Press, 2007
The annual societal economic burden associated with preterm birth in the United States was, at a minimum, $26.2 billion in 2005, or $51,600 per infant born preterm. Nearly two-thirds of this cost was for medical care, including special education services and lost productivity costs for four disabling conditions: cerebral palsy, mental retardation, vision impairment, and hearing loss. It did not include the cost of medical care beyond early childhood or caretaker costs.
Adams EK, Miller VP, Ernst C, Nishimura BK. Melvin C, Merritt R. Neonatal health care costs related to smoking during pregnancy. Health Economics. April 2002;11(3): 193-206.
The study confirms the adverse effects of smoking. Among mothers who smoke, smoking adds over $700 per mother in neonatal costs. The smoking-attributable neonatal costs in the United States represent almost $367 million in 1996 dollars; these costs vary from less than a million dollars in smaller states to over $23 million in New York. These costs are highly preventable since the adverse effects of maternal smoking occur in the short-run and can be avoided by even a temporary cessation of maternal smoking. These cost estimates can be used by managed care plans, state and local public health officials and others to evaluate alternative smoking cessation programs.

Partners

American College of Obstetricians and Gynecologists

American Academy of Pediatrics - District II

Association of Perinatal Networks of New York

Family Planning Advocates of New York State

March of Dimes

New York State Perinatal Association (NYSPA)

For more information:

Bureau of Maternal and Child Health
New York State Department of Health
Corning Tower, Room 1805
Empire State Plaza
Albany, New York 12237
Email:
Voice: 518-474-0535
Fax: 518-474-7054